HomeMy WebLinkAboutBLDP-19-002380 • Arir0 1125°
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CIN qa/MOv MrA� DATE /O i 9 -/f1 PERMIT#JW/ SB
JOBSITE ADDRESS L 1DC{hvGf P� JC?K c OWNER'S NAME
P OWNER ADDRESS 5,k TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL LtY
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR-, BSM 1 2 3 4 5 6 7 .B 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER / •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN _ __
•
INTERCEPTOR(INTERIOR) 1`( : C ! { r L -�
KITCHEN SINK
j LAVATORY _ •
ROOF DRAIN 1 it I y q
SHOWER STALL L
SERVICE/MOP SINK IIILL ING EP-AR
I TOILET i
URINAL
I WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER •
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES b 10 0
IF YOU CHECKED YES,PLEASE INDICATE
�THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTYINSURANCE POUCY �y OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
LU I hereby certify that all of the details and Information I have submitted or entered regarding this appllcatloiare_Vue and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit Issued for this application wi(Ee in compile e with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME C AJ a 5 /-e— LICENSE#/0 TSG. SIG E
MP p JP 0 / CORPORATION❑# PARTNERSHIP Q# LLC❑#
COMPANY NAME P. /- OJ A-1J?. ftfUINhi/1S ADDRESS /Z re)4 parr/ R tT
CITY ,mc STATE /0- ZIP D 24do TELPf 3r('Zy 7
FAX CELL S23 -3/5/-44/#44 EMAIL aft
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ 0 c C1,�/ � /� /1 /+I0
FEE: $ PERMIT# / 7" _�GhL (f//j '5i/e
PLAN REVIEW NOTES