HomeMy WebLinkAboutBLDP-19-000437 •
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MASSACHUSETTS UNIFORM APPUCAT1ON FOR A PERMIT TO PERFORM PLUMBING WORK
CITY t4PS'� er m(tet./ MA DATE 3- �_y ars PERMIT#id/lArg 0a'qy
/
JOBSITEADDREESSS J?4 ,ig5t�.'A R04 v OWNER'S NAME C'/q1.1 1\ 1S
OWNER ADDRESS Sr/MP/ TEL `I FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALSC
PRINT
CLEARLY NEW:0 RENOVATION:N, REPLACEMENT:❑' PLANS SUBMf TED: YES❑ NOg
FIXTURES 7 FLOOR—, ESM 1 2 3 4 5 6 7 B 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE •
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM .
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY •
ROOF DRAIN
SHOWER STALL
• SERVICE I MOP SINK
TOILET
URINAL
, ; 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 Mr•LRfi.e2£ Ti vJa.
IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BEL'w
UABIUTY INSURANCE POUCY [ i OTHERTYPEOF INDEMNITY 0 BOND o JUL 23 2018
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage re• ifh'd!b 1471TT' ,'
Massachusetts General Laws, and that my signature on this permit application waives this requirement. By. o
CHECK ONE ONLY: OWNER ❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
L:l I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to thebestof my knowledge
and that au plumbing work and installations performed under the permit issued for this application will be in comp nce with all 1 provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE#3/51( . SIGNATURE
MP ❑ - JP I� /1 / CRP-OCRATION❑# PARTNERHIP0D# LC❑#
COMPANY NAME/B a."'17 h/,( frkeleI�i �y/ ADDRESS 'O. ed>< /3)
CITY vvasr// (0/S- STATE 474 ZIP 1S 7l TEL ,r047-21g•g973
FAX CELL L/9ge_i EMAIL ���
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY Minna
NOTE
Yes No
pod- p& & //k THIS APPLICATION SERVES A5 THE PERMIT 0 ❑ �.t2v / ze
UC G (J (/�' ` FEE: $ PERMIT ll �`L le6 �/ //C1�
ksa 71-9,/fi
PLAN REVIEW NOTES