HomeMy WebLinkAboutBLDP-19-003058 •
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY '(AMLMoUTN Pa MLT MA DATE t t(14(1P PERMR#['•V✓DP-n-Opg'Q3$
JOBSITE ADDRESS LIS (Gr/360MSF(T Cfrist.r OWNERS NAME 1\V•)1(Jc Siirt S
OWNER ADDRESS TEL 114-35'c-CT7l FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW:0 RENOVATION: ❑ REPLACEMENT: ' PLANS SUBMITTED: YES 0 NO Er
FIXTURES 7 FLOOR-, BSM 1 2 3 4 5 6 7 6 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
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)KITCHE -
_� SINK C
LAVATORYI
{ .
ROOF DRAIN
SERVICE!MO { , b �,113L
• SERVICE 1 MDPP SINK
TOILET
URINAL fL _-- --
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
i -
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 1 NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THETYPEOF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY OTHERTYPEOF 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 0
SIGNATURE OF OWNER OR AGENT
111 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.
PLUMBERS NAME NIIGNA E1 It-tDo Jav4 t LICENSE# 1SLI4S • SIGNATURE
MPEEr JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME (MF,.Ireiv Pturthw44 <. PIF?vWCr ADDRESS (55.- CAPTA-*1 SI&kU_ its.
CITY S. 4mA-curt .& STATE MA- ZIP 02464 TEL 17g-19g- 16'N
FAX CELL EMAIL !It-W t i -.F bl a a •• . f•
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
^agri AAfn a,^oi THIS APPLICATION SERVES AS THE PERMIT ❑ 0 AL.
FEE: $ PERMIT II
Ia/Y /
PLAN REVIEIYNOTES