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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