HomeMy WebLinkAboutBLDP-24-172 UNIT 23 MAS ACHUSETTS UNIFORM APPLICATION FOR PE T TO PEEP PLUMBING WORK
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J CITY ,t MA DATE PERMIT#13LpP-Z`1-I 7 Z_
JOBSITE ADDRESS — S WNER'S NAME Imo_( _•
POWNER ADDRESS WA'1 �S �7d_ TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL❑ RESIDENTIAL 0
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES❑ NO 0
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/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM --
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER r ?-
DRINKING FOUNTAIN R G
FOOD DISPOSER
FLOOR I AREA DRAIN rcm j U�2�
INTERCEPTOR(INTERIOR) F��'
KAVATORY ITCHEN SINK
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LROOF DRAIN " _
SHOWER STALL
SERVICE I MOP SINK
TOILET
URINAL -
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES E
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 11 No❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE 0 RAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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.
J
T CHECK ONE ONLY: OWNER❑ AGENT❑
SIGNATURE OF OWNER OR AGENT
1-1.I I hereby certify that all of the details and information I have submitted or entered regarding this application are true a d 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 compile with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S ;,,,, LICENSE#/5C./q.i, SIGNATURE
MP JPCORPORATION❑## PARTNERSHIPa# LLC❑#
COMPANY N E e4 punivq� QRYe..v'- .. ADDRESS2 `I[ � Oil/ l/ Pei
CITY yiwy��n^1 - STATE 09+ZIP TELLTg 30C:'39 9 3
FAX CELL EMAIL rI'1 I - / • G! •
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