HomeMy WebLinkAboutBLDP-20-001459 9 c'eP w rI'`rrr.✓
• MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY C"✓11 J rh MA DATE 9/1 / z 0/ r PERMIT# C I' S?
�� ,,, JOBSITE ADDRESS 9\ I 1-1 t-j h ana A1le, OWNER'S NAME Sy/vie- 77 g—rr
POWNER ADDRESS i TEL 0a g"."i 1 t(A/FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 12
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMI I I ED: YES❑ NO❑
FIXTURES 7. FLOOR- BSM 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 x , „ '
ROOF DRAIN i •
-
iSHOWER STALL I � , 2 1q
SERVICE/MOP SINK a L s
c' TOILET
URINAL _
ij WASHING MACHINE CONNECTION r _ j
4 WATER HEATER ALL TYPES I
L WATER PIPING
OTHER
Wa+e SaPP hi a-o ;1 I
1
INSURANCE COVERAGE:
'- I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO ❑
i
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
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT 0
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 Perti ent rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 0,,,Yy)''
PLUMBER'S NAME L �yc'e/ /`16 t7 LICENSE# //.55Z., y SIGNMt RE •
MP Lld JP❑ CORPORATION El# PARTNERSHIP❑.# LLC❑1#
COMPANY NAME j C ' ''1 re-2 /IO/0'.'4'e ADDRESS a z 6 i.r"1/4 b rr. !-mod 11 e,
CITY P 1 )13 STATE/ ''Al, ZIP C) Z C 3,g/ TEL 5 a-6,19 71/1 D
FAX CELL `�0g-ry(4W-5 61 EMAIL lU n ht t v ( Coe c- 5 r ',t]L
. ji (,b— G-164
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
i
FEE: $ PERMIT# 7�
PLAN REVIEW NOTES
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