HomeMy WebLinkAboutBldp-19-000646 •
• s_\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
,= CITY Sbt)- (n V 0 rnrwc,�Li MA DATE 7/30l (7 PERMIT#/2�DP,9-000 (,L/(
JOBSITE ADDRESS ga ,ri f t 1o0p i i 1,./, OWNER'S NAME '20-6h Ag644/uA11 P
POVVNER ADDRESS 49 TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL,'"
PRINT
CLEARLY NEWZ RENOVATION: REPLACEMENT:❑ PLANS SUBMI I I ED: YES ❑ NO❑
FIXTURES 7- FLOOR--F B 1 2 3 4 5 6 7 B 9 10 11 12 13 14
BATHTUB - I 4 i _
CROSS CONNECTION DEVICE i
DEDICATED SPECIAL WASTE SYSTEM _ L.
DEDICA I EL)GAS/OIL/SAND SYSTEM _
DEDICATED GREASE SYSTEM _
DEDICATED GRAY WATER SYSTEM •
DEDICA I EU WATER RECYCLE SYSTEM _
DISHWASHER -
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK _
i LAVATORY A It L+ -
ROOF DRAIN
I SHOWER STALL 34. . 1 1
I SERVICE I MOP SINKA—Aill
TOILET 6 _ �;' S'O 4�.
URINAL
j WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING 1 _ ?�'�!
OTHER
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INSURANCE COVERAGE:
•
i I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ' NO 0
i
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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 ❑
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 ccurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complian 'th all P ' nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME t .V-% P ' �k I?..Se-CA 1 LICENSE# 1D5(9 . ' SIGNATURE
MP 14(j JP❑ CORPORATION❑# PARTNERSHIP
04 LLC❑#
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COMPANY NAME (Yl Pi c, u - 'P ADDRESS' ADDRESS 3 4I 1" r( e S ‘
CITY r pi. \ctti^k.),\\? STATE M 4 ZIP dg 6 3 a TEL SAS' >X -2 3 O
FAX
CELL EMAIL i--
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
p(4-' ( THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT It i) 9 ,e )C/'
FLAN REVIEW NOTES 'S? /F-7,7PS 5'/4-e/ e3
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