HomeMy WebLinkAboutBLDP-24-331 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
—• CITY`1( r/,0=/marred MA DATE PERMIT#l P-2H
JOBSITE ADDRESS OWNERS NAMK -,-0,4,
POWNERADDRESS C 4 9 -,ryZ TELS5-7&G-5737FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES 0 NO❑
FIXTURES 7 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
URINAL
j WASHING MACHINE CONNECTION - -
WATER HEATER ALL TYPES. _.
y` i IS..G IVED
APR l 4 2n24
UiLDiNvARTMENT INSURANCE COVERAGE:
Bu I h ye a curt liability ins irant e policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ENO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE O ERiiGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY OTHER TYPE OF INDEMNITY❑ BOND❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
J 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: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 at plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
Massachusetts Stale Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME //(/Ot7 ' , IE— LICENSE* /Jc2 SIGNATURE
MP JP❑ CORPORATION,# PARTNERSHIP❑.# LLC❑#
COMPANY NAME 7// 7,1e-, /� � �yy/ ADDRESS
CITY / /bOro �f fZ STATE/��D—! ZIP 670,7--7/ TELLL579�699 /S'C7�
FAX CELL LSe6'a)/6�`""-' EMAIL C#TT cQ) /ZW2k4,4414
e0/2
ROUGH PLUIYIBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT fl ❑
FEE: $ PERMIT #
PLAN REVIEW NOTES