HomeMy WebLinkAboutBLDP-17-006559 • /,Y boort uwz M /94)(0442190
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT'TO PERFORM PLUMBING WORK
CITY I.Z5Th l CCAA-0 (RN_ MA DATE 6-N 1'? PERMIT# A1-4P-17"Gdthaf
JOBSITEADDRESS /&? /56(er j �4v c OWNER'S NAME To\ st1k K Sq ma/'A
Y 7
OWNER ADDRESS 7 Sa kJ Shamir ,y TEL WS SSI y14.3,1 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO 0
FIXTURES 1 FLOOR-. ESM 1 2 3 4 5 6 7 8 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 k ELN
DEDICATED WATER RECYCLE SYSTEM i
DISHWASHER 4t I
DRINKING FOUNTAIN JµµU�4 4r
FOOD DISPOSER
FLOOR/AREA DRAIN - tmur.r 3L i. . Iv;:;NT
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY e'Z •
ROOF DRAIN
SHOWER STALL 4t-
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION i
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 0 NO 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POUCY ` 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.
2 CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
Ltl 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 In compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. , ' n ft_ "J
PLUMBER'S NAME Mr oitr"4e4- Pci ' eft LICENSE# y 37/, SIGNATURE
MP[9 JP 0 CORPORATION❑# PARTNERSHIP❑.# LLC IjIr# 38"/C
COMPANY NAME Q672 r r Ti / CJn.*•>✓C ADDRESS '� 2 Qt-P
CITY F et. cSTATE M '" ZIP off-Ay TEL W3-C a'4 rrY
FAX CELL N/7-CGS C7Yc' EMAIL 1° rorJ Aors;d ' cam,y4t/t COr-/
•
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
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THIS APPLICATION SERVES AS THE PERMIT El 0 ���%j��, " " P S-0
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FEE: $ PERMIT it �i �8 320- 4�4
0/-eL1�- / ' lAV/T PLAN REVIEW NOTES