HomeMy WebLinkAboutBLDP-24-232 qor 00
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
e— CITY J /eA✓MGK7� MA DATE -3/�5/Z`y PERMIT# al°it-VI- 231—
JOBSITE ADDRESS /P Cep 5"5- S}. OWNER'S NAMEEi//t-SiaC4/ Z-
POWNER ADDRESS s "`6"- TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:' REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑
FIXTURES I. 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/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
TOILET 1 - - "
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❑
IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POUCY,lg.- 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
1 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 n accu the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in cortOrdn wi all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# tWO/. SIGNATURE
MP.k' JP 0 / CORPORATION❑# PARTNERSHIP a# l LLC❑#
COMPANY NAME /'#'.t a.r?//,L /14- ADDRESS '�litruir�!/4�LC�
r CITY Solilb/// ,4, f11 ohs 3 7 STATE 41 ZIP ____ TEL.37‘e—i7r'f'.16o
i
FAX CELL-.5"Og-1 DIY?36a EMAIL
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