HomeMy WebLinkAboutBLDP-20-001550 • O gc50,,,,)e"L\ I 0-ll
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
= MA DATE 09/i1Q / /9 PERMIT#JM9`A0-6'0/S�
JOBSITE ADDRESS GZ CA 4 v P.Q. kb OWNERS NAME f ,•U L lv i LAQI JA
OWNER ADDRESS G Z CAL✓.e,k, R TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL C
PRINT
CLEARLY NEW: RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO Z.
FIXTURES 1 FLOOR—+ BSIv1 1 2 3 4 5 6 7 B 9 10 11 12 13 14
BATHTUB _
CROSS CONNECTION DEVICE I _
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 I AREA DRAIN _ _
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL •
SERVICE/MOP SINK 1 �
TOILET
URINAL
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 Er NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY INSURANCE POLICY [ OTHER TYPE OF INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
1' Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
l I hereby certify that all of the details and information I have submitted or entered regarding this application are true and of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in i nce with all Pertinent pro ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME in 126 SiGt,A LICENSE#3 SIGNATURE
395--�
MP ❑ JP E CO O jRATION 0# PARTNERSHIP❑.# / LLC❑#
COMPANY NAME• 'I� p1/+4 / 1v 1D, (.17 he4���E ADDRESS if 6- -Sui bu/y C,✓V
CITY I"(Y,Q.Ajti-;S '7 / STATE 4'l A ZIP 0 2( 01 TEL /
FAX CELL ` 77'3�00/76 EMAIL V'�CC�) iov)(. gal 4(r ('�al/iy/L ' C,0,41
C Z 'AS O'
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY INAL INSPECTION NOT
Yes No / / 14/
y
THIS APPLICATION SERVES ASTHE PERMIT ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES •
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