HomeMy WebLinkAboutBLDP-20-000101 f�sfi ni
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY > • `I14✓L O MA DATE PERMITS�#"" f*� oQ D4O/Or
JOB SITE ADDRESS 14 XL�(-4 6Q✓a.7 OWNER'S NAME / 1. f 1 Ot
OWNER ADDRESS 5Atitte TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL ISe
PRINT
CLEARLY NEW: RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7 FLOOR-* BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM •
DEDICATED WATER RECYCLE SYSTEM _
DISHWASHER •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
I LAVATORY I
ROOF DRAIN
SHOWER STALL ,
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION •
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES IZ NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY gr 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
I` 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 a accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co e ith all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER'S NAME ,�C tJL t�an/y� LICENSE# ZL,Lfc.z. ` SIGNATURE
MP El JP / CORPORATION❑# PARTNERSHIP Ell LLC❑#
COMPANY NAME 4C 14 . `'�'Q.{KO✓ ' ADDRESS 1 .77 Pe1A(,C ‘41'y1Gdde/
CITY C cadet/1 t'e STATE 10144 ZIP 016P 32, TEL
FAX CELL 6 ' -IO#370 EMAIL /GreeQ 66 gar :CDDLa(
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
p a // THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
tPW7-- &i
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/7 FEE: $ PERMIT#
PLAN REVIEW NOTES Agd