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HomeMy WebLinkAboutBLDP-19-002855 NIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY 1/14 i n.u.4.1-I. n MA DATE I/l f / 1 PERMIT#141--07/9-04/6J JOBSITE ADDRESS / Advw lea) 61/ OWNER'S NAME hem"r` Iek-in OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL Fa- PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:E .-- PLANS SUBMITTED: YES ❑ NO(2 FIXTURES 7 FLOOR-+ BSM 1 2 3 4 5 6 7 6 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE • DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM • DEDICATED GREASE SYSTEM _ DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER _ FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK �i LAVATORY • „C ` d E 1 N E, D ROOF DRAIN SHOWER STALL �n�n • SERVICE I MOP SINK La i TOILET I URINAL .Y1CtII4L ucroic TM NT • 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�ff0 ❑ IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABILITYINSURANCE POUCY OTHER TYPEOFINDEMNITY 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 �r 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 LAI I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and Installations performed under the permit issued for this application will be frycpmplance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1(Ir/0 ) - PLUMBER'S NAME LICENSE#m'//c0 r SIGNATURE MP [ P❑ Oki • CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME ti-� \ 11 ?L k� ADDRESS 1 O 5 Clibi ©p p� CITY 1 V l G, c 1,j STATE 1445 ZIP O . 4, / '/I/TEL /SW 5311 D2 V2 FAX CELL EMAIL f .a I d F�(1 (gig/// • C 00.4 Gd? if C L I SID ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes Na THIS APPLICATION SERVES AS THE PERMIT 0 0 Y c FEE: $ PERMIT It D� £ //" PLAN REVIEW NOTES G iSa g ti tMASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No qq, � �/ THIS APPLICATION SERVES AS THE PERMIT 0 0 JL� £ 4- 37 l—f/ice FEE: $ PERMIT f! � ELAN REVIEW NOTES ` �?. ' vA • • r