HomeMy WebLinkAboutBLDP-19-003725 •
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY f,IrcS1 Vnts.AcatrH MA DATE 1)f t4(IP, PERMIT#/ t)*-0097t S
JOBSITE ADDRESS 2A tool a 03 OWNER'S NAME )cit . Ocit3O N10
OWNER ADDRESS TEL 114-3S%-CLfl2. FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Er
PRINT �/
CLEARLY NEW:2✓ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
FIXTURES 7 FLOOR—r 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 I AREA DRAIN
INTERCEPTOR(INTERIOR) ry
KITCHEN SINK ! ` • r+ +_
fi LAVATORY I I ( 1
ROOF DRAIN i ! f
SHOWER STALL f tt" -L ZIIh 1
SERVICE I MOP SINK ! f 1
I TOILET ( i V"'""t '�1tr,
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 IE NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE 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
J Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR 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 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 MtC EQ_ d— toNCdn.;.1 LICENSE# ( 44'>. 1 SIGNATURE
MP Er JP❑ CORPORATION❑# PARTNERSHIP Q# LLC❑#
COMPANY NAME ChteiAl PWMhujC 4 tteNttalCG ADDRESS I 5T GkttMr1 smAta— 211
CITY S . YIYIMOUM STATE 'Wt ZIP 694G L TEL `7`1 K r 49 r( - 189
FAX CELL EMAIL Ocia 1t•IWN.C.MA*AC.e YhHOO. tneA
4 &o GK 14-
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
pp it G ^fir' THIS APPLICATION SERVES AS THE PERMIT 0 0 I�%� /i. M.L/�a /G/ ( or
� /
`/ ( FEE: $ PERMITf fiie /j�/ [ 9
1- L- Mol/a"
C a" PLAN REVIEW NOTES