HomeMy WebLinkAboutBLDP-19-002335 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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_1F=^>5 CITY �'(1 snatni� \� MA DATE �0/ ij I� PERMIT#�DPl? °QU%
JOBSITEADDRESS 3I Gr7' ja CiIr� OWNER'S NAME ! QJt Gel AIthog✓
P OW `
NER ADDRESS SA✓v . TE(Satog
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TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO 0
FIXTURES 1 FLOOR—• BSM 1 2 3 4 5 6 7 8 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 —t
FLOOR I AREA DRAIN �—. r,� c r R! k0
INTERCEPTOR(INTERIOR) + 1
KITCHEN SINK A ! /t t
j LAVATORY _f 9C 1 b 610 I
ROOF DRAIN l
SHOWER STALLj3 1 C/
FF aRT1� .� U
SERVICE I MOP SINK
TOILET
URINAL
i WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER f e_., hitp+r f
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESpg NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIU1YINSURANCE POLICY tgl OTHER TYPE OFINDEMNITY 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
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' 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
L:I I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accura - o the .- of my • o -dge
and that all plumbing work and Installations performed under the permit Issued for this application will be In�� �-r'� • ' i.'of I.-
Massachusetts State Plumbing Code and Chapter''// 142 of
theppneral Laws. ��
PLUMBER'S NAME A"Kin"hi St t'%OSfUc LICENSE# JZa3,3 SIGNAT 1'
MP❑ IP❑ CORPORATION RI#334-5 PARTNERSHIP❑.# LL ■#
COMPANY NAME /1 \,t t /YJ j( nn,(yq !/ Lie ADDRESS 3°6 Chu l t/d\?/ Rti 1))**** *�
CITY 8 re tel Tit' STATE mol ZIP 0263 ,- Ta )o 7 ^96 f
FAX CELL Wa "- EMAIL • / ,i i '2
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
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FEE: $ PERMIT# '' // /- �(
PLAN REVIEW NOTES Cie l- //�� i