HomeMy WebLinkAboutBLDP-24-277 4ID.Dd
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY�4fW1Glk MA DATE 3-dso-g / PERMIT#CJL v29'0777
JOBSITE ADDRESS /077 f (3.2 OWNERS NAME MAly "Kam
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL' EDUCATIONAL❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION:' REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO[X
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/OILISAND SYSTEM _
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN /
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL p ,`
I TOILET SERVICE I MOP SINK e7,,r-S�lG r D
i URINAL ......�.._..
WASHING MACHINE CONNECTION _ r M-2�
WATER HEATER ALL TYPES [UC'i
WATER PIPING I+ 2 / --
OTHER
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ll gar / rsuwIn ULIANK 1MRNT
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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. YES NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY yr, 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❑ AGENT❑
SIGNATURE OF OWNER OR AGENT
L:I I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate t e best of my knowledge
and that at plumbing work and Installations performed under the permit issued for this application will be in comp' nce ith all rent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE#gIg7>. SIGNATURE
MP❑ JP d )) ) CORPORATION❑# PARTNERS IP❑.# LLC❑#
COMPANY NAME /�e.CS f p)[vlvl 41fgtiy1 ADDRESS V,Dq J9N4i �/ c
CITY PgrYr1{6 k n STATE "V _ ZIP U.�6�j ✓/TEL d ° -OY_-7
FAX CELL EMAIL
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