HomeMy WebLinkAboutBLDP-20-002572 L/
MA �!SSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY rG c/1'1�tJ l '�! /
MA DATE II l (� PERMIT#
JOBSITE ADDRESS 500 l/CJ(,GL /$/aqd r- /�j OWNER'S NAME
OWNERADDRESSg ad. 4,6.. G fd 'Y5 TEL 72q 3 3-D3SZFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL TZIf
PRINT
CLEARLY NEW O. RENOVATION:❑ REPLACEMENT:Ei PLANS SUBMITTED: YES 0 NO 0
FIXTURES 7 FLOOR-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB /
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
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DEDICATED GRAY WATER SYSTEM 1 —
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER •
DRINKING FOUNTAIN
FOOD DISPOSER "
FLOOR/AREA DRAIN - -
INTERCEPTOR(INTERIOR)
KITCHEN SINK -
LAVATORY IRECEt f
ROOF DRAIN
SHOWER STALL
I SERVICE/MOP SINK - .
TOILET
URINAL - b rWi
�t ��r c -r�Crw
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
1111 I I
INSURANCE COVERAGE:
i I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142.. YES K. NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY OTHER TYPE OF INDEMNITY 0 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.
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CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
�'1 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 all plumbing work and installations performed under the permit issued for this application will be in co n'-with aiI-P nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1'
GJ [(a�
PLUMBER'S NAME 4ndrer.J u r✓ LICENSE ?jZ(00 SIGNATURE
MP JP( I CORPORATION❑# PARTNERSHIP 0.# LLC❑#
COMPANY NAME Thd I t " ADDRESS 5‘ ./lG ci
c/ Y'1
CITY SGI/./(f °L4 STATE 1 ZIP .moo TEL �Z—6 7�
FAX CELL So 6 F 7 EMAIL /'�/ /�-� gUZL�d V 6444d(
e/7L CV4ID(a so— C
ROUGH PLUMBING INSPECTION NOTES
BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ ,t3 '/}/�C
FEE: $ PERMIT# /I // // /7
PLAN REVIEW NOTES
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