HomeMy WebLinkAboutBLDP-24-254 MASSACHUSETTS UNIF RM APPLICATION FOR A PERMIT 0 PERFORM PLUMBING WORK
1�• CITY CvlV\.lAq( (Ii0 Air( MA DATE D Z PERMIT# - ' ,
JOBSITE ADDRESS J 4CI- arr6awl OWNER'S NAME iI1i S C 9 /('
P OWNER ADDRESS/ /11d14 y7--- 2I4- 77/ TEL 4,;?..-/Fliz) FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL K ? EDUCATIONAL❑ RESIDENTIAL ig
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Xl. PLANS SUBMITTED: YES❑ NO❑
FIXTURES? FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 .1
BATHTUB
CROSS CONNECTION DEVICE _ _
DEDICATED SPECIAL WASTE SYSTEM _ _
DEDICATED GAS/OIUSAND 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
SERVICE I MOP SINK _
I TOILET
j URINAL - _
1 WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES /
WATER PIPING _ _
! OTHER
I
i INSURANCE COVERAGE:
1 I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES k NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY k 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.
CHECK ONE ONLY: OWNER❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
L11 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. q (1 (� _ _
PLUMBER'S NAME LICENSE#//W�/ x IC SIGNATURE
MP❑ JP 0 (.1 CORPORATION(� / 0# PARTNERSHIP❑.#
COMPANY NAME !NV()V C-I GNU P J `� ADDRESS 3 7 pro()
Ili/❑�Trr `'qn(/'C�
CITY 1 4 '^N l 5 STATE kV+ ZIP O Z(J a / TEL 7 7 l 7(6) //ZL
FAX CELL EMAIL' 11I))-PJ'.!h nL_d_711,J''41C.•/i),A/Y
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