HomeMy WebLinkAboutBLDP-18-004667 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK /
- _ CITY '(/4Rvnu0-Tµ MA DATE 42o1)c' �PERMIT 13 Oi ooy(�1�7
JOBSITE ADDRESS S Abe/\.S 12d. OWNER'S NAME A)bc, —re r be
POWNER ADDRESS S•4yY1E TEL 6.--O -,h.L7- 94//r FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL E EDUCATIONAL ❑ RESIDENTIAL la
PRINT
CLEARLY NEW:❑ RENOVATION:4 REPLACEMENT:❑ PLANS SUBMI I I ED: YES ❑ NO❑
FIXTURES T FLOOR BSIJM 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 1\IA\ ‘../ •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
'''.11-7--1)/- \1 ' .
INTERCEPTOR(INTERIOR)
KITCHEN SINK
'i. LAVATORY I' .
ROOF DRAIN
SHOWER STALL .-- ,b. -
SERVICE/MOP SINK • ' n E V E G
i TOILET ( ' r..
k
URINAL
•
WASHING MACHINE CONNECTION 2(� 9
WATER HEATER ALL TYPES .a
WATER PIPING =' r A N-
OTHER r
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY A OTHER TYPE OF INDEMNITY ❑ BOND 0
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
i` Massachusetts General Laws, and that my signature on this permit application waives this requirement.
- CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
L1 I hereby certify that all of the details and information I have submitted or entered regarding this application are true an. accurate to- e best f my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in mplia e with l P nent ovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i
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PLUMBERS NAME /Ja f ha,i DVOr$ki LICENSE* 333g7- SIGNATURE
MP ❑ JP E CORPORATION❑# PARTNERSHIP❑.# / LLC ID#
COMPANY NAME LI_ %/ R' t46,„i6, �Jr Ai 4 ?tic?ADDRESS 1 f eAcie / 4e/
CITY Roc b{c ✓ l STATE j/14 ZIP 2/7 ) 0 TEL 57*- 7) - y7Y 7
FAX CELLSAri16. %a EMAIL /,af MA/1CI✓0/';SI' 6)6 MA L , (0vvt r
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OFFICE USE ONLY FINAL INSPECTION NOTES 1
BELOW FOR
ROUGH PLUIVIBING INSPECTION NOTES
Yes No ?/L3/y 671)Ud—Q7FMf7�"
107 a
21 (.. ,
0 THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
�( PERMIT tt ' 17��
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PLAN REVIEW NOTES `_ 7I 6,t- f c�ineerL.-
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