HomeMy WebLinkAboutBLDP-23-11707 4 3/4, 50967 Rex aI
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S7J, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT T PERFORM PLUMBING WORK
1-=_ ?- • CITY c 1 Ma .DATE I J�y PERMIT# •b tram'Z -i/'?a/
JOBSITE ADDRESS 12,/7 /%�peJJ I OWNER'S NAME),y
ty,i 5r.--L. SOWNER ADDRESS I 2 7-/7 /� 4A d i�r / I/ke I wls= /(FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL lb
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:EI PLANS SUBMITTED: YES 0 NO0
FIXTURES 1 FLOOR BSM 1 J 2 J 3 I 4 5 6 4 7 J 8 1 9 10 1 11 J 12 J 13 1 14
BATHTUB 1
,
CROSS CONNECTION DEVICE B•
DEDICATED SPECIAL WASTE SYSTEM „ . •
DEDICATED GAS/OIUSAND SYSTEM - •
DEDICATED GREASE SYSTEM Tei - , IWa a , ,.
DEDICATED GRAY WATER SYSTEM , '
DEDICATED WATER RECYCLE SYSTEM .
DISHWASHER - I
DRINKING FOUNTAIN R '
it _ _ ,
FOOD DISPOSER
FLOOR/AREA DRAIN a i 1,
INTERCEPTOR(INTERIOR '• i
KITCHEN SINK • .L.: _ �• ! -
LAVATORY 1 ,
ROOF DRAIN
SHOWER STALL '
=IMIIIMINIMMOI
SERVICE/MOP SINK 111 all ' 4sr -
TOILET
URINAL __ -- ‘
WASHING MACHINE CONNECTION - I +'
WATER HEATER ALL TYPES
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WATER PIPING i -- � . *,r-_
OTHER . ' -
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INSURANCE COVERAGE: •
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.14R teS 'e:. t10N.E 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW — _
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND❑ SEP 1.4 2023
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required . c i ARTMENT
Massachusetts General Laws,and that my signature on this permit application waives this requirement. By:
CHECK ONE ONLY: OWNER ❑ 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 Pertinent provision of the
Massachusetts State Plbing a and Chapter 142 of General Laws. ZL �—�
PLUMBER'S NAME A"-(c 'C- &c'7'1 U&--? ILICENSE#J/7h?:$I I SIGNATURE • —
MP JP'I- to "C 1 CORPORATION❑#I (PARTNERSHIP❑# LLC❑#J - I
COMPANY NAME NV-- 13 rI/9-Q I ADDRESS 3 f (r;,A' -1//) ,c67 1
CITY g 4'4 J S 1 STATE EtWal ZIP () ? 6 0/ ( TEL 177 I T/6 9/
_ FAX I I CEu.I I EMAIL I • '