HomeMy WebLinkAboutBLDP-24-392 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
-ear= CITY y/+R/HouTH �-T4- 39 2-
MA DATE /he l 13-l9` PERMIT 0
JOBSITE ADDRESS 37 .42N44E//544 OR OWNERS NAME r47,09,N//40a✓
OWNER ADDRESS 3T LaNeFe-/bw Da TEL FAX_
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO❑
FIXTURES 1 FLOOR-' BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14
BATHTUB _
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIDIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY _
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK - •-
6 �CL. �
I TOILET
URINAWASHING
1 A'R 2 3 28214
WASHING MACHINE CONNECTION 1
WATER HEATER ALL TYPES t
WATER PIPING GUILD NV U=�nnTmnr="R
OTHER Y - L
/ U�Ia^//34uc-"4OJ /
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES p'NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER❑ AGENT❑
SIGNATURE OF OWNER OR AGENT
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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General laws.
PLUMBERS NAME /32,A./A//"'"-' 7 LICENSE#//nil . SIGNATURE
MP Z' JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME Kl•*ti+y P/""‘ S-tos''E' ADDRESS /Sic/i
CITY /draw:«,- STATE /t ZIP 026H-5- TEL sop'Z76 44'4'0
FAX CELL EMAIL .Cone
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT [ I I
FEE: $ PERMIT #
PLAN REVIEW NOTES