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HomeMy WebLinkAboutBldp-19-006524 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY Cli �'`'1�/'1CU T7y MA DATE 5�7�1 ��/ PERMIT#/9L4 7'00,0 JOBSITE ADDRESS 3 c (� P 779/ti" Aid i:C.5 OWNER'S NAME e/t/ L=G POWNER ADDRESS TEL FAX ��2Y TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL(\ PRINT CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 7. FLOOR-7 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER / _ T DRINKING FOUNTAIN _ FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY I I 1 • ROOF DRAIN _ SHOWER STALL SERVICE/MOP SINK TOILET t'l URINAL WASHING MACHINE CONNECTION I WATER HEATER ALL TYPES WATER PIPING ► _ _ _ OTHER 1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YEA NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY e OTHER TYPE OF INDEMNITY ❑ BOND ❑ 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 ❑ SIGNATURE OF OWNER OR AGENT �/ Q 72 I I hereby certify that all of the details and information I have submitted or entere egarding this a cation are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for t i ica ion will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the GenerallLaws. s PLUMBER'S NAME 3 4 K�''t 7'(( K v L�4O CENSE# ��Cf Z-) SIGNATURE MP ❑ JP CORPORATION©# 560.2 PARTNERSHIP❑.# LLC❑# COMPANY NAME 72/) 1 /L /)//f-6 /1/6- ADDRESS 77 S fie c t r , CITY - i(iO4'r$' STATE /�j9 ZIP 7 L) TEL 77Y 3i 7 U.TV FAX CELL EMAIL /' r' 779T/2/7 o • cf>ey ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES On° Yes No //L�f /�P/7/- THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ i --z 7 17 I- FEE: $ PERMIT# ��/�� PLAN REVIEW NOTES d PE //