HomeMy WebLinkAboutBLDP-24-276 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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�==1€F_=a` 0•� MA DATE 3' ?.�' 2� PERMR# /,"7LTP�a,��",,,a2�7�
JOBSITE ADDRESS " t•.J C.49kcS 0'C� -i' OWNER'S NAME D .�Yrt1 \YET
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIALAL
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:0,, PLANS SUBMITTED:YES❑ NO 0
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/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM T
DEDICATED WATER RECYCLE SYSTEM _
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY •
ROOF DRAIN
SHOWER STALL R E.L r
SERVICE I MOP SINK
TOILET MAR URINAL PI 1 R 2 t3 2
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES BUILDING IJ E PART M ENT
WATER PIPING
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.142. YF NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
14.I 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 Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# 1 Z L 13 v` SIGNATURE
MP JP 0 CORPORATION❑# PARTNERSHIP❑.# LLC 0#
COMPANY NAME C' 4 t �N ADDRESS 3ds.k. +s,11h
CITY l—pc B,v )�Jc/" g7 STATE%-lAA ZIP b 3 L0 1 TEL
FAX CELL 7Y " —a go EMAIL C .��1Y�LI�6.� A' C)0.,1 Ww-
-1,64-IU rjQ
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT #
PLAN REVIEW NOTES