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HomeMy WebLinkAboutBLDP-20-000994 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK `_=1 -4 CITY v/1�AA41, 0'Tl e I'R / MA / DR`DATE t-� PERMIT# P ?7V JOBSITE//ADDRESS //`A-A/�dtL'1*C )i ' OWNER'S NAME d T1"/N p gill au POWNER ADDRESS lei Zt" l U (--`)/iG-- d .P TEL /©CSS��A.0 igrii-Ax TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Er------ PRINT CLEARLY NEW:Zs RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES E NO FIXTURES-1. 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 _ rpC C DEDICATED GRAY WATER SYSTEM 'l I DEDICATED WATER RECYCLE SYSTEM DISHWASHER _ AUG 9 _f DRINKING FOUNTAIN ^ FOOD DISPOSER ., BUILDING )EPA 4 FLOOR/AREA DRAIN By. i INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY � _ ROOF DRAIN SHOWER STALL . SERVICE/MOP SINK _ _ TOILET URINAL AlWASHING MACHINE CONNECTION WATER HEATER ALL TYPES ✓ 'Z WATER PIPING t . _ a OTHER o; INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES eNO 0 1IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY l OTHER TYPE OF INDEMNITY 0 BOND 0 O OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the j' Massachusetts General Laws,and that my signature on this permit application waives this requirement. . FLI _r r/ • V' I ' - CHECK ONE ONLY: OWNER [AGENT El SIGNATURE OF OWNER OR AGENT rl 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 iance 'th all Pertin provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# 31`.. S TURE MP ❑ JP❑ CORPORATION❑# PARTNERSHIP❑/.# LLCQ 0# COMPANY NAME T �^L-���/ a''1. ADDRESS p� l t �/�11t (. c) CITY o4VI�J �Ck y1� 0 c� S` 1 CJV �/V� � STATE�y r !� I�' ZIP d-�� � TEL FAX CELL J v� (�O 4'O((' • //(26 ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ El FEE: $ PERMIT It / Old 740 PLAN REVIEW NOTES • •