HomeMy WebLinkAboutBLDP-19-002569 •
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
,_--i-__� a CITY U&k51 VAA.Mcv'1U MA DATE ‘o 1S (\a PERMR#/Wrfl o0C J
JOBSITEADDRESS 10 CYGpC-C OWNER'S NAME Sot Mo,Aii1
P OWNER ADDRESS ' 13oL 2,( TEL 5o8-2.o -1112 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT ^/
CLEARLY NEW:LK RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO Er
FIXTURES I FLOOR-, BSIv 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
LAVATORY • - n
ROOF DRAIN
SHOWER STALL
•
SERVICE MOP SINK OCt 95 714
I TOILET
URINAL �If ILDI C nn AR ENT
WASHING MACHINE CONNECTION I 1 _ter_ —
WATER HEATER ALL TYPES �
WATER PIPING
OTHER
INSURANCE COVERAGE: 1
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES EI NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POUCY e OTHER TYPE OF INDEMNITY 0 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 application waives this requirement
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CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
1-1.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.
PLUMBER'S NAME to c#4 9._rt_ Downuti.l LICENSE# ‘S`4%-k3. �SIGNATUR`
MP ELr JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME t )+-sola•- Q\t'-iAWC cctvAithts ADDRESS 14c CAPTktw4 SMksJ Q.-t .
CITY 5. VeACOttk STATE MPc ZIP 62CG TEL`114-114 - 1811
FAX CELL EMAIL tAtsv30UVS 44 av \L. Co NA
ROUGH PLUMBING INSPECTION NOTES f,ELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No _
N / /. THIS APPLICATION SERVES AS THE PERMIT 0 0 irP_. /IC /71--g
`7 I//1140 FEE: $ PERMIT#
PLAN REVIEW NOTES ///q