HomeMy WebLinkAboutBLDP-20-000366 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
Val! CITY 9PC/111‘111- GA DATE 1-3 l', PERMIT#Ba/'6CEJ-$QS' �o
JOBSITE ADDRESS GI/jr n I,�nit mid OWNER'S NAME 2"U, "
OWNER ADDRESS r ✓Pc hoi1Q( (i r c-/f TEL?7 t/99 7(93 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 2,
PRINT �f
CLEARLY NEW:Cd RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO
FIXTURES 1 FLOOR-, 8SM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIIJSAND SYSTEM .
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM _
DEDICATED WATER RECYCLE SYSTEM _
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY I +�—
ROOF DRAIN RECEIVED
SHOWER STALL
SERVICE I MOP SINK TOILET / JUL 2 2 [�1 u19
URINAL .�
WASHING MACHINE CONNECTION R I l l t DING u t rA R T M E N T
WATER HEATER ALL TYPES By
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a anent liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑. NO 14(
IF YOU CHECKED YES,PLEASE INDICATE TIDE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ 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 GENT ❑
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 aft plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME y�' 0(/' Gi /.1 //Lr✓A-) LICENSE##947-142/ SIGNATURE
MP Et/ JP CORPORATION El# PARTNERSHIP❑# LLC❑#
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COMPANY NAME vt!/4'1 /'7' /vo101„/J ADDRESS a.- ✓eGy1 I/J 41.P !!r".4l
CITY i0"-"A//71fW STATE /)/ ZIP 49-- cr73 TEL 72 4/ 9i/7 .7
FAX CELL 7 7419 9 yI:1'g r EMAIL
10 CV la3
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APP (CATION SERVES AS THE PERMIT ❑ 0 lvy/ b
drp O FEE: $ PERMIT# Z-/ -ll /O o7/�
p joip G/J 000M7/9 PLAN REVIEW NOTES
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