HomeMy WebLinkAboutBLDP-18-000868 /3P-/ r-aaoBw
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY 44S? MA DATE PERMIT# � 11/—
JOBSITE ADDRESS foe- 4 or 4e../. OWNER'S NAME/1/4-'4 CO Ldecic_//
•
P OWNER ADDRESS TEL 1 7 3 `/-f O?6/FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
FIXTURES-1 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/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM _
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
RECEAVE- D
KITCHEN SINK
LAVATORY
ROOF DRAIN RIG 1 �+i
�Ln�7
SHOWER STALL • f�
SERVICE/MOP SINK
TOILET Y r__
URINAL
. WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER //e(/s'-ewer h,..k
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YE NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYP OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POUCY 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
LU I hereby certify that all of the details and Information I have submitted or entered regarding this application a : ' a- . ac - et. . e best of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be I .mplian = y... • 'vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Alk /`
PLUMBER'S NAME LICENSE# /32 G) SIGNATURE
MP[E' JP❑ _ )CORPORATION❑# PARTNERSHIP 04 LLC 0#
COMPANYNAME9PC-1 /4-0
L0tinGrc . /fit ADDRESS 8 4/ I/w Clete /
CITY�r1 STATE/7/4 ZIP O2 C G TELSC%_R V4')2R-1
FAX CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT
PLAN REVIEW NOTES