HomeMy WebLinkAboutBLDP-19-002568 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK.
_L{= CIN "(ALAW'S 1\YJLT MA DATE tel 15 le PERM R# /5.4)/299)-12:76414u
JOBSITE ADDRESS 143 l�.>;rsec SETC LtdGLE- OWNER'S NAME `bEaYJk SNOrtra
OWNER ADDRESS TEL-1111-3S 3-0712 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL Er
PRINT
CLEARLY NEW:0 RENOVATION:e' REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 1:3"-
FIXTURES
FIXTURES 1 FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 1
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
FLOOR/AREA DRAIN _
INTERCEPTOR(INTERIOR) i •
KITCHEN SINK R CE I r ;
LAVATORY •
ROOF DRAIN -OCT
SHOWER STALL
2-3 frita
SERVICE/MOP SINK r_
I TOILET ` surLiNc.DLNAItrMENT
URINAL aY _
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 V NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCEPOUCY 121/. OTHER TYPE OF INDEMNITY ❑ 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
CHECK ONE ONLY: OWNER 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT
LU 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.
PLUMBER'S NAMEMUWc9, it- `ba Wh,.r LICENSE# 6%-N3 . SIGNATURE
MP JP 0 CORPORATION 0# PARTNERSHIP Q# LLC❑#
COMPANY NAME1)OWJkn YIuIntl.Vs 4 NPATtrJG- ADDRESS t3S GcltMN St-tb&3.-
CITY S. ' ,M4oQt\ STATE iMN- ZIP Dace TEL 114-59 -t$14
FAX CELL EMAIL Voth)NloJA+Jt5443 eGMkt-Lori
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
/////�� �/� 0-11°
THIS APPLICATION SERVES AS THE PERMIT ❑ 0 r�Y�r � . /02-/�
/ `� `r " l FEE: $ PERMIT It /C 4%L
PLAN REVIEW NOTES /!/ '/ 7/r