HomeMy WebLinkAboutBLDP-15-002412 „.a '.•� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
‘ x=
7 iD/-�� 1Y �j
-ill .
CITY C1 ('rYY®t'./ ��/�/� / MA DATE PERMIT#�J//�I�/S� o�Iy/ot
JOBSITEADDRESS Ma/5(oWpv L ', OWNER'S NAME CrPPlALArnad
P OWNER ADDRESS tP 1 r”:TEL — r ^ FAX
— 1 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 .EDUCATIONAL 0 RESIDENTIAL
PRINTCLEARLY NEW:0 RENOVATION:0 REPLACEMENTS I i OCT 2 8 ZO PLANS SUBMITTED: YES 0 NO 0
FIXTURES1 FLOOR-0 BSM 1 2 3 4 5 ; '"'6" ^`7"' r'8 6 1•941 110 11 12 13 14
BATHTUB -------
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM _
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN ,
FOOD DISPOSER
FLOOR 1 AREA DRAIN -
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY •
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES f
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(O ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POLICY 1�4 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 ONLY: OWNE' • AGENT 0
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 accurat- o the •-s of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be in compliance i a •- - t p•.vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / p
PLUMBER'S NAME RE es Oh _/LICENSE# i sry4Qa : GNATURE
MPg JP❑ CORPORATIONS 36(a PARTNERSHIP❑# LLC❑#
COMPANY NAME (Brc j Q 81-05' -4-711° ADDRESS l [ I° 8 r r e c 15 k i l/ {RJ 45
CIN 1'x'1
q '1 /3 STATE � v V f- ZIP of P 0/ TEL -77 ff—'1I 7—79 5/
FAX CELL EMAIL p
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes Na
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
-A
FEE: S PERMIT#
PLAN REVIEW NOTES