HomeMy WebLinkAboutBLDP-15-000400 t MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY to pinoi(t hpa l MA DATE g / PERMIT#04°-/ -ea, yd zr
JOBSITE ADDRESS/6- SJR-I9LU A qZ P 41 • OWNER'S NAME rPE E.E K-W
P OWNER ADDRESS /t t it TELS-Oi-%2 347/ FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL Z'
PRINT PLANS SUBMITTED: YES 0 NO❑
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:
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 GAS/OILISAND SYSTEM
DEDICATED GREASE SYSTEM - -
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM I
DISHWASHER .
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN - - -
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN -
SHOWER STALL
SERVICE 1 MOP SINK -
TOILET
URINAL
WASHING MACHINE C! . a
WATIRHEATEWALt11PES F U
WAT€F{FtIF S 6 Y
0TH R ( '7
Nub 06 2014 -
BUILDING
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YE' 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 ElOWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laa'and that-my signature on this permit application waives this requirement
CHECK ONE ONLY: OWNER AGENT 0
SIGNAT RE 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 tgthe best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance al�ertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ---7t,a, E.t4-,.--
PLUMBER'S NAME ni A j:�:L0&.0 cli LICENSE# /J 9€7 SIGNATURE
MP1p'( P / CORPORATION I�J#2'1 22 C PARTNERSHIP❑# / LLC❑#
COMPANYflNAMEAGEW .:Pfini'f o�*Alin'I 6- ADDRESS .AL3 Lincoln Ace, q
CITY 2/4,0 cit lie- STATE}114 ZIP 0. 74 02 TEL -6c14-CC'S- /
FAXS-tS3-4qq-SS_c O CELL EMAI fes' a '(V a r,1 . 4) '^ jrta , IC-
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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