HomeMy WebLinkAboutBLDP-18-005254 _.- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
e CITY 5eLi 77( y i � MA DATE 3-/9-2-6 / - PERMIT#/✓' l'-17-,85P i
JOBSITE ADDRESS 351 ."- /A'a)'7 92. OWNERS NAME 14/%(t'r
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL IJ
PRINT
CLEARLY NEW:❑ RENOVATION: V 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 rz,, _
DEDICATED WATER RECYCLE SYSTEM _
DISHWASHER • • _
DRINKING FOUNTAIN r
FOOD DISPOSER
FLOOR/AREA DRAIN _
INTERCEPTOR(INTERIOR)
KITCHEN SINK __
I LAVATORY Z �� �' . W;
ROOF DRAIN 4 --
SHOWER STALL k�l9 .
SERVICE/MOP SINK ' ., t r _
TOILET 2_ t
^URINAL o ; ' `'
WASHING MACHINE CONNECTION / ` _._,-,._ 1---
WATER HEATER ALL TYPES '
WATER PIPING / _ _
OTHER
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I INSURANCE COVERAGE: /
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[�' NO ❑
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
It Massachusetts General Laws, and that my signature on this permit application waives this requirement.
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CHECK ONE ONLY: OWNER 11 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 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 compliance,. ith.4II Pertineyntpr�vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. '
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PLUMBERS NAME iiI/A Y.le �nPu i)S LICENSE# '3/ S-.''/ .. ' `�I IGNATURE
MP E JP 2/ CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME E9 j.istiW S Pet 14 ADDRESS Z:: ,4 114E Ira Nf
CIT //
Y ,•5i Y ,140—r STATE M 4 ZIP 412"6 73 TEL .7 7 7- r3( - 2S 3Y-
FAX CELL EMAIL 14yAJG 'Tui CLvlvyi t&eM4 _,: M
. LAW- /0q0 4
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
074 / ��/f /y�- THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ '
`gl !j ,9 �U FEE: $ PERMIT# r- -)441 /4 — ' " 9
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PLAN REVIEW NOTES 7"' /T
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