HomeMy WebLinkAboutBLDP-23-11907 MASSACHUSETTS UNIFORM APPLICATION FOR A ERMIT TO PERFORM PLUMBING WORK
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• CITY G�,r. rf'/M iv o MA DATE 2 PERMIT#ak, L 3 //9O7
�Ai(/R` Z rS� OWNER'S NAME 5-jr)1 mil\t l'."9JOBSITE ADDRESS J
OWNER ADDRESS TEL -7ye C)l 1/2 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL In EDUCATIONAL 0 RE^ iS
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED:YES❑ NO
FIXTURES? FLOOR-r 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/AREA DRAIN
INTERCEPTOR(INTERIOR)KITCHEN SINK f—FR /+r
J L L_ a., D-
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LAVATORY L_2- T r, 1 / PGROOF DRAIN n 2423
SHOWER STALL _
SERVICE/MOP SINK
TOILET ( v
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER J'44�Q\ic.
C 1
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES k NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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
i Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT❑
SIGNATURE OF OWNER OR AGENT
L l 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 Plumbilf Code and
Chapter 142 of the,General Laws.
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PLUMBER'S NAME;�1 coot L " IN\- ` LICENSE# SIGNATURE
MP❑ JP 0 CORPORATION 0# ("6)h PARTNERSHIP❑.# LLC❑-#.
COMPANY NAMEN L( c I CX(- W f'I ADDRESS / 7 FreN,1 `/�? n /' Lit
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CITY fs—Al ' 1 / S STATE ' ZIP Q 7, Q / TEL 77 y 774 9/2 t
FAX CELL EMAIL 1:10—.I cJ/r r., rvi4-i L,
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