HomeMy WebLinkAboutBLDP-15-000008 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY YarturA4.- _ MA DATE 7_4 / PEPJJIT/�
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JOBSITE•ADDRESS /d 57 (,i-'JI -' OWNERS RAMS GC',.. C�Lail lG
p OWNERADDPF4 TEL FAX
TYPE OR OCCUPANCYTYPE COMMERCIAL 0 EDUCATIONAL 0 P.ESIDETIAL&
PRINT � RENOVATION: SUBMITTED:CLEARLY NEW: 0 REPLACEMENT:0 PLANS SUBM ED: YES 0 NO ❑
FIXTURES 2 FLOOR-0 I BSMT 11 2 I 3 4 5 16 17 18 9 I 10 I 11 I 12 I 13 14
BATHTUB
CROSS CONNECTION DEVICE I I I I I I I I I I
DEDICATED SPECIALWASTE SYS I I I I I I I I I
DEDICATED GAS/DILISAND SYS I I I I I I I I
DEDICATED GREASE SYS I I I I I I
DEDICATD GRAY WATE:SYS I I I I I I I I
DEDICATED WATER RECYCLE SYS I I I I I I I
DRINIONG FOUNTAIN I I I I I I I
DISHWASHER I I I I I I
FOOD DISPOSER I I I I I I I
FLOOR/AREA DRAIN I I I I I I I
INTERCEPTOR(INTERIOR) I I I I I • I I
KITCHEN SINK I I I I I I
LAVATORY
ROOF DRAIN-
I I I I I I I
SHOWER STALL I I I I I L I I
SERVICE 1 MOP SINK • I I I I I r I I
TOILET I I I I I • I I I I
URINAL
WASHING MACHINE CONNECTION I I I I I I I I I I
WATER HEAT 3r .ALL TYPES I I I I I I I
WATER P>PING . I I I I I I i I
OTHER+ e' c,.ri'k c
ritnif4C4S I I I I I I I I I I
JUI Al11 I INSURANCE COVERAGE
I ve a rre—liability Insurance policy or ifs substantial equivalent which,mets the requirements of MGL Ch 142 Yes ]`No❑
BUILDU;,;) UCHECYES,PLEASE NDICATETHETYPE OFCOVERAGE BYCHECKING THE APPROPRIATE BOX BELOW
RITYJINSURANCE POLICY, 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 if
Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE BOX ONLY: OWNER 0 AGENT 0 •
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) regarding this applction are true and accurate to t
best of my Knowledge and that all plumbing work and installations performed under the permit Issued for this application will be
compliance with all Pertinent provisionroof the Massachusetts State Plumbing Code and Cha- a General Laws.
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PLUMBER NAME 4 goy t'cat-1a SIGNATU
Meg/r72-YY li/Pl1� JP CORPORATION 0# PARNERSHIP 0I 11 #
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COMPANY NAIVE eN4k\ok Qa-1-4 Hi- ADDRESS: �X V.-22S
CITY /U Ea.siL •H
ott STATE - ZIP di21c7 EMAIL'
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TEL CELScR-'237' n 71> FAX
j ,ONLY FINAL TN
1-1E-ION NOTES
ROUGII PLUMBING TNSPIrCTCON NOTES Mrs ROR CNSPCCCOR TJ T
Yee No
In S :P _ C 01 SE -S .S - �� 0 0
FEE: S_ PERMIT 1f__----
nt a ur�y W N 1�1'1$S •
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