HomeMy WebLinkAboutBLDP-19-002998 T�
MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORKRK ypQ,
1,"TL �,. CITY Yi'r lefil6i%h IZ 1 MA DATE /// pi i r PERMIT#,9P//y-V •icy
JOBSITE ADDRESS 3.2 ( ASTri-Su mo d- OWNERS NAME i3 .l rillate
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL El.
PRINT ^�
CLEARLY NEW❑ RENOVATION:❑ REPLACEMENT:ICJ' PLANS SUBMITTED:YES D NO 0
FIXTURES•1 FLOOR-, BSM 1 2 3 4 5 6 7 J 8 9 10 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
T -
DRINKING FOUNTAIN
FOOD DISPOSER _
FLOOR/AREA DRAIN -
INTERCEPTOR(INTERIOR) _
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL .
SERVICE I MOP SINK R _
TOILET __
URINAL _ _
WASHING MACHINE CONNECTION U 8 4 IB
WATER HEATER ALL TYPES fit
WATER PIPING _ei7,4F`,1._•A TMErT
OTHER „v
.tn)Le( C?,Mr31 J
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ' NO❑
IF YOU CHECKED YES,PI FLSE INDICATE THE E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITI INSURANCE POUCY[ OTHERTYPEOF 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
1 Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER❑ AGENT❑
SIGNATURE OF OWNER OR AGENT
�1 I hereby certify that all of the details and information I have submitted or entered regarding this application are true and as; -e to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in com fir. . ,� Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4. 4�%
PLUMBER'S NAME LICENSE# /99GG' SIGNATURE
MP❑ JP❑ CORPORATION 0# PARTNERSHIP❑# LLC 0#
COMPANY NAME ADDRESS /3 6 3 Tj ,
CITY A1/_5 ( I4/i//Ia,NNIS T STATE /V{FI ZIP 32 ,7 a TEL t-ov3'.2.37/dI9
FAX / CELL EMAIL iScd,f/G,_e 9Ft j4iL,( v
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ROUGH PLUIYMBJNG INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT
FEE: $ PERMIT It
PLAN REVIEW NOTES
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