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HomeMy WebLinkAboutBLDP-20-002940 • (' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY Gj MA DATE !Q 2 ! % 7 PERMIT#ESP JOBSITE ADDRESS 3 G` ' I J rt "�(2 L O OWNERS NAME ) 4 c.-LZ 'e (/I POWNER ADDRESS T7TEL 77/ 0 0 5-7 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES ❑ NO(ir FIXTURES-1 FLOOR--+ BSIJW 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 DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN -� INTERCEPTOR(INTERIOR) KITCHEN SINK L,_._ , LAVATORY »7�TT ROOF DRAIN SHOWER STALL S SERVICE/MOP SINK NOV is i i 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 g NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [;1S. OTHER TYPE OF INDEMNITY 0 BOND ❑ 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. - 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 with all Pertinent provision of the Massachusetts State Plumbing C e and Chapter 142of the Genera aws. (` / �•- PLUMBERS NAME ��\ - L f '� C)3 r , t 7 (� b 9 � �- LICENSE# SIGNATURE MP ❑ JP ❑ CORPORATION❑/# PARTNERSHIP❑.# LLC❑# prop - COMPANY NAME " '�47 ADDRESS 9 /2 VS gc Jr j otto \ CITY v`J STATE ZIP () 7 73 TEL 27 y Y7� FAX CELL EMAIL 5 n5 r114 rJCo 0, `j N, -cr ' (•cA., • a:44 1eo o-s ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT/t /21 ,A& ©!i PLAN REVIEW NOTES Gr`/ /// (1( 7 • • t+ .