HomeMy WebLinkAboutBLDP-24-35 MASSACHUSETTS UNIFORM APPLICATION FOR A PE IT TO PERFORM PLUMBING' WORK
V.
CITY S YQ m rrv7lj MA DATE / / Q
1 PERMIT# , ,P-ay-31C
-
JOBSITE ADDRESS ' / Q7 �-gf OWNER'S NAME �4nSM4h_ I1(Ik4I✓t
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL["
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Er-- PLANS SUBMITTED: YES❑ NO 0
FIXTURES 1 FLOOR-, BSM 1 2 3 4 5 6 7 B 9 10 11 12 J 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)
KITCHEN SINK - -
LAVATORY
ROOF DRAIN -
SHOWER STALL ,'
SERVICE/MOP SINK I C •
TOILET R .Si
URINAL 4fraWASHING MACHINE CONNECTION 13 �Q '
WATER HEATER ALL TYPES I I
WATER PIPING L DEPAR1M;ry
O p U�
OTHERr4Ir' Ilroi“- PiPe- / a..._
�Ct
=
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 E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTIY 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
I 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
LI 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 pprPplla=_ all PeQtnent provision of the
Massachusetts State Plumbing� Code an Chapter 2 of the General Laws. //�/Jrv_ �,/'//Y„�_t
PLUMBER'S NAME Uo V vA/54 LICENSE# Icy SIGNATURE
MP JP❑ Q [ t CORPORATION 0# PARTNERSHIP Q# LLC❑#
COMPANY NAME 1.)6 1S ✓rlAAS ADDRESS 04,1- 00 &SS plwr RQ
CITY 1) 4A15 STATE (nP ZIP 0J-63g.-- TEL/
FAX CELL) 35-3 Sry7/ EMAIL INIfifAsCef fCiavd,cOM
(Ail )11do1 CO 4' 1c/O ,COfn
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT I
FEE: $ PERMIT #
PLAN REVIEW NOTES