HomeMy WebLinkAboutBLDP-23-11930 •
MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
CITY i<i r Or.1- 1 MA DATE /2- " �- 3 PERMIT#BL9P'Z3'//7O
JOBSITE ADDRESS 11 I 2.1fs/ 'ca✓1d. 1(A OWNERS NAME-7,1\1-1
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES 0 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 GASIOIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR) �" G_
KITCHEN SINK /tE
LAVATORY
ROOF DRAIN
SHOWER STALL • au'L.1-1+a<;
SERVICE I MOP SINK _ �ANTME(T
TOILET --
j URINAL
j WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES J
WATER PIPING _
OTHER
Tl
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES In NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY [ 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
J Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
LU I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the bestbe of my la) edge
and that all plumbing work and Installations performed under the permit issued for this application will be In compliance allneE'C vtsio e
Massachusetts State Plumbing Code and Chapte 142 of the General Laws. ✓/y{'i,
PLUMBER' AME -)tCl c-V� C. LICENSE# I 316 rf. / SIGNATURE
MP JP 0 CORPORATION 0# PARTNERSHIP❑.# LLC 0#
COMPANY NAME L%1� \ur D{H 1 R/e /l ADDRESS PO &iC z2-12 f
CITY C) ISii1&> / STATE { ZIP 0 .173 TEL /
FAX CELL S- h�I
-67(1 2'130 EMAIL C_ U i--�11__I nC1 13 �y enci/I,
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