HomeMy WebLinkAboutBLDP-19-002582 MASSACHUSETTS UNIFORM APPLJCATION FORA PERMIT TO PERFORM PLUMBING WORK
CITY
7A rtn o fT�h MA DATE !o 9- $
Lf- PERMIT#/:+r-/V-149'6Vo2 57
JOBSITE ADDRESS 6 6 fLr$ Gc ` t• 19 ^r S" OWNER'S NAME STACIVIrd
OWNER ADDRESS 6 F+Rrs{ 614+a tr 1-x18Slwt 't TEacg1$Se'474J FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:ig PLANS SUBMITTED: YES 0 NO 0
FIXTURES 1 FLOOR-. ASH 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM •
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK 4
LAVATORY
ROOF DRAIN
SHOWER STALL
•
SERVICE I MOP SINK
I TOILET
URINAL 9 E g i r f .r WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING Or 2 '
OTHER T{{msCtic(Inc
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BY; -K'5/I✓✓S
INSURANCE COVERAGE: i7
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 21, NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY t%I OTHER TYPE OF INDEMNITY ❑ 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 ap?lication waives this requirement
i CHECK ONE ONLY: OWNER 0 AGENT ❑
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 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. c
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PLUMBERS NAME 6-4"y f``k LICENSE# a oil ' U SIGNATURE
MP❑ JP ] CORPORATION❑# PARTNERSHIP J# LLC❑#
COMPANY NAME 6C.6Sc6°tr tCe wnd n�Savr�c ADDRESS Ili 5-12C t
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CITY IAA )1/Ifrrnn•11" STATE in ZIP 41)" TE65°n'"�74a
FAX CEi 1(1°0-11?- J Y 3 4 EMAIL COCe ti 'a eyi.{.m.r of^
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
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1 tYes No
P O 11-- /2 /7 THIS APPLICATION SERVES AS FHE PERMIT 0 0 PP/141
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/l�t4/I PLAN REVIEW NOTES
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