HomeMy WebLinkAboutBLDP-19-002570 $� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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•=a a CIN QMO�1tN Qod.T MA DATE lot aS (If1 PERMIT#42.0)Wera
JOBSITE ADDRESS 28 <,UJIFrt gee" I A ac- OWNER'S NAME t i '
I P OWNER ADDRESS TEL 1'$-3s3FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL T
PRINT �/
CLEARLY NEW:❑ RENOVATION:EJ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ N0el
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 I
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK E i VE L
LAVATORY L.1
ROOF DRAIN OCTSHOWER STALL O2 3 2013
SERVICE/MOP SINK
TOILET {}--
URINAL 13 t. ILIAC Dtf`AftT 41cr17
WASHING MACHINE CONNECTION r
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 El NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY YJ OTHER TYPE OF INDEMNITY 0 BOND ❑
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
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CHECK ONE ONLY: OWNER 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT
14.I 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.
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PLUMBER'S NAME MtGNKa.. Q_ 'Pa Uoka1/4J LICENSE# t54 t 3 . IG RE
MP V JP 0 CORPORATION 0# PARTNERSHIP❑.# LLC❑#
COMPANYNAME'ba,td./As PuntepJa c cIVATUJIr ADDRESS t3S Gtttkt$ St-tka itb.
CITY 5. YMMa rtvt STATE NAS, ZIP O1GG4 TEL ,114-114 ' 1814
FAX CELL EMAIL MDO,Jovaatcy4�C&/�1,,MMl .Cot.
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ r‘ j/t/7 - 19�
FEE: $ PERMIT St /9k7
PLAN REVIEW NOTES (�///,
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