HomeMy WebLinkAboutBLDP-24-142 cottage #7 1720
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MASSACHUSETTS UNIFORMAPPLICATION FOR A PERMIT T PERFORMPLUMBING7r�O
WORK
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MA DATE PE MIT# ��IUf' Z l 0(2
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JOBSITE ADDRESS OWNER'S NAME�•.�J l
POWNER ADDRESS TEL FAX_
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL L '
PRINT
CLEARLY NEW:❑ RENOVATION:V REPLACEMENT:' PLANS SUBMITTED: YES 5,14:10 0
FIXTURES Z FLOOR-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14-
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM a
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM 1
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN — g- -
INTERCEPTOR(INTERIOR) --i- ^d
KITCHEN SINK
LAVATORY - r i FEB-1 2,2024, -
ROOF DRAIN i - -
SHOWER STALL 3 ituih e-razrMrIv
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING C ,�}��-/}-�-q.� -
OTHER P,A ni s - e A-/�V V J
INSURANCE COVERAGE: -
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY OTHER TYPE OF INDEMNITY 0 BOND❑
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 0 AGENT❑
SIGNATURE OF OWNER OR AGENT
�1 I hereby certify that all of the details and information I have submitted or entered regarding this application are true and,ccurate to the best of my knowledge
and that ail plumbing work and installations performed under the permit issued for this application will be In compllan th all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NA_ME 4 ilir bPcuL, LICENSE# G5yqI, SIGNATURE
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{'�, {//, ` CORPORATION❑# PARTNERSHIP❑.#./7 I,t r 1/LLC❑#
COMPANY NAME
IMay-7-4"'r✓rig"T /9 4'1 nA ADDRESS�I^7J�G d (V/V Y
CITY V 4� STATE!'4� ZIP ( TEL
FAX CELL EMAI 1
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