HomeMy WebLinkAboutBLDP-24-235 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
--:_f=9 CITY \1 A R. n o V C'tMA DATE 'l, I.a. ` PERMIT#tiLDP-tti-tic-
_ JOBS‘ADDRESS ADDRESS 5 1 RI . ER'S NAME
POWNER ADDRESS 1 Cr. 1Z I 1P--. TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 121/ ED RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Er PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 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/OILISAND SYSTEM
DEDICATED GREASE SYSTEM -
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM -
DISHWASHER -
DRINKING FOUNTAIN -
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) -
KITCHEN SINK -
1 LAVATORY •
ROOF DRAIN T-
SHOWER STALL - R E 7, C i
SERVICE/MOP SINK r—
..r_i
TOILET MAR 07 2024 1
URINAL
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WASHING MACHINE CONNECTION --- .'DrVARTMFIJT_
WATER HEATER ALL TYPES _ _ �r
WATER PIPING _
Qo OTHER
4NEvop p "
t INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES rt6 NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY[11 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.
T CHECK ONE ONLY: OWNER 0 AGENT❑
SIGNATURE OF OWNER OR AGENT
4.1 I hereby certify that all of the details and information I have submitted or entered regarding this application are true an•accu t.'•-bes • my knowled.
and that all plumbing work and Installations performed under the permit issued for this application will-..co r .. a ;r j ion of v
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
i
PLUMBER'S NAME LICENSE# 0 0 Lp 0,:, SIGNATURE
MP® JP❑ /V p &CORPORATION.(-]# PARTNERSHIP
❑.# LLC 0#
COMPANY NAME ( ® R f RR ADDRESS 4 `AW F)C ,LA' �j
CITY v.a N 0 i' 11 . STATE M'Ifs ZIP°&��a �r TEL 6 1( 5 II 4
FAX CELL l l P`5 EMAILU sg-R N Li Pa( r c/9 of c a./
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