HomeMy WebLinkAboutBLDP-24-710- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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/\ MA DATE 1i-Z6,-z y PERMIT# 5LDP_241- '1 SO
JOBSfrE ADDRESS�-1 /Y/Gry David
Kd OWNERS NAME Leo�1Q 13resio(A.)
POWNER ADDRESS / TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL 13'
PRINT /
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:[9" PLANS SUBMITTED:YES 0 NO 0
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 GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER •
-
DRINKING FOUNTAIN
FOOD DISPOSER _
FLOOR/AREA DRAIN _
INTERCEPTOR(INTERIORL
KITCHEN SINK
LAVATORY
ROOF DRAIN 7R C y I V E 0 _-
SHOWER STALL I- —- _ 'w
SERVICE/MOP SINK I APR TOILET _ APR 2-6 ail!
URINAL _ _
WASHING MACHINE CONNECTION _ BUILDING utpAR:MFpL
WATER HEATER ALL TYPES / Lur _---------
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 B" NO 0
IF YOU CHECKED YES,PLEASE INDICATE VP OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POUCY Ly 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❑ AGENT❑
SIGNATURE OF OWNER OR AGENT
l.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 in compliance with all Pertinent vlsl n of ih
Massachusetts State Plumbing Code and ChaptIr 142 of the General Laws.
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PLUMBERS NAME 131-1.U,,�/1 Cl a, LICENSE# f 3/6`. SIGNATURE -
MP JP❑ CORPORATION 0# PARTNERSHIP❑.# LLC 0#
COMPANY NJ B NAME P ''[ j n u(At)bAi 4-1- ADDRESS To T 2 '8
CITY !,1L1!CiM SS�� STATE f144- ZIP 0 -63j TEL
FAX CELL 562))-'30 l-7'13d EMAIL�1p�\V i / C oct7
ClC-i156
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