HomeMy WebLinkAboutBLDP-20-002801 •
MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM PLUMBING WORK
--alt=:= CITY MA DATE �/ �� /R PERMIT#lJl✓_/=_____V (
JOB ADDRESS OWNER'S NAME r'(', l'7 �_
POWNER ADDRESS TEL �15/M/c AX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT EIV
CLEARLY NEW:0. RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO
12'-
FIXTURES 1 FLOOR-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB - L 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 m "
INTERCEPTOR(INTERIOR) . t rr
KITCHEN SINK
_
LAVATORY NOV. `� ���9
ROOF DRAIN
SHOWER STALL fill+-.. , .,ra;31 -—
'
SERVICE/MOP SINK "V
TOILET -
URINAL _ J
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
• INSUR
ANCE COVERAGE:
i I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES I`f' NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Er 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.
sk
r CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
Lk4 I hereby certify that all of the details and information I have submitted or entered regarding this applicatio - : true a accurate to ._. .f my knowledge
and that all plumbing work and installations performed under the permit issued for this application will •= in.s mpf with III P • . ision of the
Massachusetts State Plumbing ode and Chapter 142 of tt a General Laws. `/t
PLUMBER'S NAME \I v '2 GO LICENSE#100 ` glfATURE
MP I' JP❑ CO ORATIO # PARTNERSHIP❑.# LLC<y/6.J
COMPANY NAME �, / oar / ' �, 1
���DDRESS P'�C ���' ,c1���7/
CITY L lG61/-6 1 /G STA f ZIP CV .._ TEL 5"
FAX ,Rik--- � L ' 3�
CELL 77/2 3 EMAIL/ 0Ct` 29 • /j7
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NO ES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ 1. -PA/A/"fr 7)Z, 6, C1'7-7°
V / �9
FEE: $ PERMIT# ;if— //
PLAN REVIEW NOTES
•
•
•
• i
I
1
_ i