HomeMy WebLinkAboutBLDP-23-11977 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY V//4.4% vYk MA DATE /Z/242.3 PERMIT# ,B4:9P.?3—J)17
17
JOBSITEADDRESS 023-2 31 v! R✓Gk .?2 NO// 1) L(S
OWNER'S NAME � iF
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION:[R REPLACEMENT:® PLANS SUBMITTED:YES❑ NO Did
FIXTURES 7 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 19 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER •
DRINKING FOUNTAIN
FOOD DISPOSER _
FLOOR I AREA DRAIN _
INTERCEPTOR(INTERIOR) E r V 2- 13
KITCHEN SINK•
LAVATORY /
ROOF DRAIN 2 I
SHOWER STALL / ��'
SERVICE I MOP SINK _ RI III Dl ve U' 1 .EN I '
TOILET —
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
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❑ NO I2S
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POUCY 0 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,
�a ynd that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER® AGENT 0
SIGNATURE OF OWNER OR AGENT
L1-1 I hereby certify that all of the details and information I have submitted or entered regarding this application am 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 co pliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# 10175'. SIGNATURE
MP Er JP 0 n CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME C tIr21 f S£JL11-J 1 ADDRESS t o/' 3?�
CITyIN—MO� p'r-e STATE Ai- ZIP GZ67,j'-03"7✓ TEL)k 3c 2 Ot_S
FAX CELL EMAIL olvl i 11u ;)M4'6Q,�£ „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