HomeMy WebLinkAboutBLDP-15-000344 1 , MASSACHUSE ITTIF
S UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY *f mOa:HI 1 r/t2 1LMA DATE 7/2k / PERMIT# /31-0P/6-CCO 7/?
JOBSITE ADDRESS 7 Con eRn Lh . OWNER'S NAME #V/O(jrick 5
POWNER ADDRESS '( C( Ci TEL 7N-99a-.2 91, FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL%
PRINT SUBMITTED: YES 0 NO❑
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:cgc
FIXTURES 1 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 GASIOILISAND 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
SERVICE!MOP SINK
TOILET •
URINAL
WASHING MACHINE CONNECTION
WAT ' '
WAT glpllwc, C E I t 1
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JUL 30 2Cilt
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r,1�NT
nulLG.,iG :� # ,� INSURANCE COVERAGE:
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I have firm,r insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YEK NO
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:lam aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Lawc and thaMhv signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER AGENT 0
SIGNAT R OWNER OR AGENT my
I hereby certify that all of the details and information I have submitted or entered regarding t�6an pplicaillte Intion aretrul nand accurate
tg th best
st of ion knowledge
and that all plumbing work and installations performed under the permit issued for this appl
the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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Plan=PLUMBER'S NAME 1 an= O�tc l EA_ LICENSE# /19 f 7 / SIGNATURE
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JJP 0 CORPORATI/ON N#2l ?1 C PARTNERSHIP 0# J LLC 0#
COMPANYI.
NAME/66.44a' 2 n113141 *Arm 6- ADDRESS .2 Lincoln 4G.,
CITY?hint), lit STATE in 4 SS: ZIP Ca-7 <1. TEL -6C4-CSS 9
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)SSt�s'GCIC['���0 CELL EMAI /� a. %.t . CEf .4-, •,;..
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: E PERMIT#
PLAN REVIEW NOTES