HomeMy WebLinkAboutBLDP-20-001193 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY Si, Y4i i 47i MA DATE / r 3 -2-0(9 PERMIT# <1•)fi-01? Iqi
JOBSITE ADDRESS ,S 7 8-' i Gc/oar) 2)e. OWNER'S NAME //A
OWNER ADDRESS d 44-6777/./6 ', TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT �,/
CLEARLY NEW:❑ RENOVATION:(Ll . REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES Z FLOOR BSIvi 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE _
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OILISAND SYSTEM
DEDICATED GREASE SYSTEM _
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK —
LAVATORY ( •
1 RE C E t
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK ( 3 0 ' _
TOILET j f s
i URINAL ,-u,;_Dir;:; or:?Mi'Ttii{..
WASHING MACHINE CONNECTION -- —
WATER HEATER ALL TYPES
WATER PIPING
OTHER
i -
INSURANCE COVERAGE: ,,_,/
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES FQ NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ( 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
it 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 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 'th all Pertinent rovisi n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME j-r//4Yivc 62,‹ 4p5- LICENSE# 3're/. SIGNATURE
MP 0 JP lV CORPORATION❑# PARTNERSHIP 0.# LLC❑#
COMPANY NAME 690.46005 P ,/ ADDRESS � 8� G
,./ L4'v
CITY LC/• Y,4Q•Gracin( STATE �.(,�( ZIP 0 '23 TEL ?7f' 2%-3( •'Z-s-3
FAX CELL EMAIL ki/4 rWePe2MTE3Ce �GI*14/C.debt/
GIBVI ��-
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ i {j1_ /n
11 ( / FEE: $ PERMIT# ���C ////f//7
PLAN REVIEW NOTES
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