HomeMy WebLinkAboutBLDP-24-136 cottage #1 MASSACHUSETTS UNIFORM APPLICATION FOR A P RMIT TO PERFORM PLUMBING WORK
`.€r ', CITY Y4' . )O U- MA DATE
,/� PE MIT#B(-OP-r'1-17f.
-241147—q
JOBSITE ADDRESS � fG YOWNER'S NAME ---r
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL LS}'
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CLEARLY NEW:0 RENOVATION:2/ REPLACEMENT:[ PLANS SUBMITTED:YES L140❑
FIXTURES 7 FLOOR-r BSM 1 2 3 4 5 6 7 6 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) -
LAVATORY NK -• F-KITCHEN ^- 1 D-
ROOF DRAIN
SHOWER STALL -
: f EK 12 4 -
SERVICE 1 MOP SINK
TOILET BUI_DINC DEPF_RTtENT
URINAL By __
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER 1RI INs7- re'c_72MI T
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES IN NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY 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
1 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
-U I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and curate to the best of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be in complian 'th all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME/ 4 D'�A{�� oPoU I-0S LICENSE A G�LIQr SIGNATURE
MP N7 JP N1L. ` r�CORPORATION 0# PARTNERSHIP❑.# LLC❑#
COMPANY.NAME I 'v t3 T/"r ie 4-1-1 ADDRESS�S^4'�l 4-Ain-kw!Y
CITY `/4�04OVT STATE Mr9 7
ZIP ( TEL
FAX CELL EMAI
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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