HomeMy WebLinkAboutBLDP-24-350 /SD,
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
--�— CITY \/ f MA DATE It 11 I a y PERMIT#f3( OP"Z'1' 3 Cl/
JOBSITE ADDRESS aa_ { A„ OWNERS NAME 'k'^I.` 1A4CDomow/It
OWNER ADDRESS TEL PO°�a/ 7 t61 FAX !
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL ga
PRINT
CLEARLY NEW:0 RENOVATION:g REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO 0
FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 7 6 9 10 11 12 13 14
BATHTUB 1
CROSS CONNECTION DEVICE _ _
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER 1
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN _
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY •
ROOF DRAIN
SHOWER STALL
SEORVEICf E I MOP SINK R E-e + ' V F
TURINAL [�
WATER HEATER ALLCTYPESCTION
WATER PIPING 1(tt�ILI"NG DiLPHrc I MEN I
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YEA) NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY t 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 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
I 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 incaance 'h all P n ntM grovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �`//
PLUMBER'S NAME LICENSE#7 b 36 . GNATURE
MP 12i- JP 0 CORPORATION 0# PARTNERSHIP❑# LLC 0#
COMPANY NAME ADDRESS 6 a 38 S.r or, PA
CITY V.LMli) STATE� L
GdA- ZIP 0a 6 3 t TEL
FAX CELLr S A Y J 3 69 l'1 11 v EMAIL 1'01 K Roc/wL Q C.j"r14.s..1 t-..K e
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