HomeMy WebLinkAboutBldp-20-002601 ----,...._7. ..- I MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
CITY WQS1 �,r'� Qv► �T MA DATE ) 1-1-1- 19 PERMIT#/�ICP' ?-- 0/
JOBSITE ADDRESS 17 S veN ADZ.Z. OWNER'S NAME g ` �
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL Lld'
PRINT
CLEARLY NEW❑, RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO
FIXTURES 1 FLOOR-4 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/OIUSAND SYSTEM �^
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR1
KITCHEN SINK
j LAVATORY I r
ROOF DRAIN
SHOWER STALL ,
SERVICE/MOP SINK
TOILET
URINAL r
NOV
WASHING MACHINE CONNECTION l ' i
WATER HEATER ALL TYPES
WATER PIPING ni` r r b b{
OTHER ._
• INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO 0
IF YOU CHECKED YES,PLEASE INDICATE TH TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY INSURANCE POUCY OTHER TYPE OF INDEMNITY 0 BOND 0
i 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.
SIGNATURE OF OWNER OR AGENT
CHECK ONE 0 • OWNER 0 AGENT 0
L'I I hereby certify that all of the details and information I have submitted or entered regarding this application /
and that al plumbing work and installations performed under the permit issued for this application will be in mp rate to the best of my knowledge
Massachusetts State Plumbing Code and C
pter 142 of the General Laws. ;,
PLUMBER'S NAMEa.,Lo, � QC�� ' ' 3 �1.
,
LICENSE#� SIGNATURE
MP Er JP❑ CORPORATJON❑# PARTNERSHIP❑.# LLC 0#
COMPANY NAME fl1tk''r 4t U"3 `1- J'lt +�%'C 0 C 7S
CITY AN o.( STATE ►I 4,, ZIP a L TEL 0 `fl —
FAX
CELL 54 12z--1 %a) EMAIL "' 9Q. I 0
4 C /(03
ROUGH pl,UIyIBING I
ECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 ❑ /"�� Q�
FEE: $
PERMIT# L A /C
PLAN REVIEW NOTES
•
•
•
•