HomeMy WebLinkAboutBLDP-19-003555 i /*CHS ) 0,efro
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
4 CITY yl AK4OZ1771 IM DATE /2-/7-/P PERMIT#I -U/"1I-009,rf-r
JOBSITE ADDRESS /'/%/ /14/07e-e-Weelli 1/1/ OWNER'S NAME /tl/Cate
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL[t}—
PRINT
CLEARLY NEW❑ RENOVATION: 0 REPLACEMENT:0% PLANS SUBMITTED: YES❑ NO —
FIXTURES 7 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
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) — —
_ KITCHEN SINK j L I t. U
LAVATORY
ROOF DRAIN sr ' "f 0o ' —
• SHOWER STALL 1 1 Aalu
SERVICE I MOP SINK
TOILET IME T
URINAL -
i 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 L3 NO 0
IF YOU CHECKED YES,PLEASE INDICATE
ETTHE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 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
Jr 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 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 come lance wi all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME it.<Ctldt.O a.et7eeJ— LICENSE# fart' SIG URE
MP tom " JP❑ CORPORATION 0# PARTNERSHIP Q# LLC❑#
COMPANY NAME 8447`fer AtpalL ADDRESS 7 .04/76fy4-i r Aarttx ctZ.
CITY /9-6UdC a STATE .4f4- ZIP 09.0€4— TEL.Cce -'32az r
FAX CELL BAILS/flier A,6U/4 Com'/ aavtiCarin. 1,
ROUGH PLUMBING INSPECTION NOTES JIELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 ❑
FEE: $ PERMIT 8 1 �. /
PLAN REVIEW NOTES Z—g77— /0%
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