HomeMy WebLinkAboutBLDP-14-001464 -;-' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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Wirt CITY WQsr yA-GLin,uu7 ..h . . MA DATE 9/?. -// PERMIT# /ftp`/✓�/%q
JOBSITE ADDRESS// /7 Vire 9,'Oi q .5* OWNER'S NAME&River f f nu R„tp,,1p,,,,.
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:[A PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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BATHTUB —�-�—I f—�� 1—� i��—
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CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM1..___,•1.__ ,• l 1
DEDICATED GAS/OIUSANDSYSTEM __ 1 —�—� I I I—��-1 �'
DEDICATED GREASE SYSTEM I - I I . . 1—I-7 , I - I t I . . .. , _( !
DEDICATED GRAY WATER SYSTEM —1--1 1_1 _ 1 , 1 -- . I I
DEDICATED WATER RECYCLE SYSTEM —11-1--I-1-1—� —�' 1, 1 --Ii��
DISHWASHER I I— I _I I I I ( I I
DRINKING FOUNTAIN j —I 1 -� -
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FOOD DISPOSER 1— I —I I— I I . 1 1 I
FLOOR/AREA DRAIN — I I_, j--1 — i 1 1
INTERCEPTOR(INTERIOR) —II 1 --ir — 1-1 I 1 1 1 . I- 1
KITCHEN SINK 1-1- 1 I I 1 I I 1
LAVATORY 1 I_ L—I^. ! I- 1. P --1 . , .t.m . i . 1
ROOF DRAIN i__ 1 i� 1-1 i . I 1- , i-�
SHOWER STALL ThTh 7.7--ITh I —.1 II I . ---_. I I I
SERVICE/MOP SINK I I— I 1 —i . . 1 , L_ i 1 1
. TOILET _-1' I—li— 1 - - - I—I I— ITh
URINAL —1 -7 I — I--. I _ I I I I I
WASHING MACHINE CONNECTION 1 I i i I— i I —1-1 --1
WATER}IEATERALL PES. -r -`
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=v .—\- --/' '4- INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES'' NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICYt� OTHER TYPE OF INDEMNITY❑ 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: OWNER ❑ AGENT El
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 accurate to the best of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will In compliance ' all Bertinent 'sion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME eftfFECy S 7je,ccocc LICENSE# /3695 SIGNATURE
MP JP CORPORATION❑# PARTNERSHIPE# LLC❑#
COMPANY NAME Cc Pfeay 5.112,scocc 11.04,04ADDREss /9S PounaCo✓e Eo*D.
CITY . EAS—, /f,igtwieN . STATE /Yl a- ZIP 6).4,y5- TEL ,Soc& -9'3a--8974,
FAX 5f -rnE CELL 77/-353-41.41 EMAIL fLASIinc//t(.c,,,/iPr Ova-kDe, .sena _ '
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ 0
FEE: $ PERMIT#
PLAN REVIEW NOTES
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