HomeMy WebLinkAboutBLDP-13-845 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY Y M,c-mo(1't w- MA DATE 6 i vi/3 PERMIT# 915- 8Lic
JOBSITE ADDRESSc� _ OWNER'S NAME p,6- / Q V P-090I
P OWNER ADDRESS 966 t 1/14-()J SrS .e c TEI(e/1 &%'6 —3o5NFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 a• TIONAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO 0
FIXTURES 1 FLOOR— I BSMT 11 2 3 1 4 5 5171819 10 I 11 I 12 13 14
BATHTUB I /
CROSS CONNECTION DEVICE I I
DEDICATED SPECIAL WASTE SYS
DEDICATED GAS/OIL/SAND SYS
DEDICATED GREASE SYS
DEDICATD GRAY WATER SYS
DEDICATED WATER RECYCLE SYS
DRINKING FOUNTAIN
DISHWASHER I I J
FOOD DISPOSERII I
FLOOR/AREA DIN I
INTERCEPTOR(INT RIOR) I I /o /��/�I l
KITCHEN SINK fOtrittl
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LAVATORY I •
ROOF DRAIN"- In. ) f - I -
SHOWER STALL
SERVICE/MOP SINK
TOILET •
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER I I
/" V 8 t5/b site_ vldt_vL I
• INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which,meets the requirements of MGL Ch.142. Yes 0 No 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE BOX ONLY: OWNER 0 AGENT 0
Signature of Owner or Owners Agent
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 ermit issued for this application will be in
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Cha r 142 of the General Laws.
PLUMBER WANE C (o ,- W v2-rz-ho SIGNATURE
LIC# I 6-L G`f MP[ JP❑ CORPORATION ❑# PARTNERSHIP ❑# LLD ❑#
COMPANY NAME S di-C P C.VI-41(i tilt) ADDRESS: 233 Vic rd, t tt1 �-'-t)
CRY @JlJVGy STATE frill- ZIP 0247/ EMAIL S (L /C t Inj5/0.1- 2 CCMCP$T
TEL Cl `r- 9 - SOSo CELL CS?- 7Iy'3s92 FAX 6f7- 474 - oGjo3 .
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ROUGH PLUMBING INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY
FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
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