HomeMy WebLinkAboutBLDP-15-001926 (fid
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
TRW— CITY yoJVT`nOUW- MA DATE IJ-Oth 1y PERMIT# I3d0P-1 'c117fo2G
JOBSITEADDRESS P MP ' N lePd"t OWNER'S NAME MM ) tkw'N
OWNER ADDRESS I'( (Slut 11104 ' M_ TEL S30-91! 1447 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL 3
PRINT
CLEARLY NEW:❑ RENOVATION:a' REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO El-
FIXTURES 1 FLOOR-0 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
LAVATORY
ROOF DRAIN
SHOWER STALL a
SERVICE 1 MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
FtEICF ! S/ F a.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ctk 142. YES®_ Z3
OCT 1 �j i
4
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOY.
LIABILITY INSURANCE POLICY s OTHER TYPE OF INDEMNITY ❑ BOND ❑ BUll e 7:55 F9\23 p6.14
ENT
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the • how c0
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 a 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 PertinentArovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �/ � F OI I
t it-
PLUMBER'S NAME 6)tie t FetYtit\ LICENSE# c cj q Q SIGNATUREE
NPR- JP❑ CORPORATION❑# PARTNERSHIP 17:1#nn^ n LLC❑#
COMPANY NAME ADDRESS ` IID 01`l�Y�\(AJ U)
CIT Scti Du fAC� 51)%40-0'700
I r `\ ZIP �hg9 '7 TEL C t8 P-1) - a0
FAX 50%'' bb'-06i; CELL 4D-0700 EMAILffrPehte 06/he-A)W 'V3 , cru. •
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
/04_4, 67f2-48 /D011ly` Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ 0
FEE: $ PERMIT#
PLAN REVIEW NOTES