HomeMy WebLinkAboutBLDP-24-436 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
CITY yA1tAtOln14 MA DATE 5'3'zy PERMIT#CLOP--2`/- i3C
JOBSITEADDRESS 32 (LEEL CAVE 0t _ OWNEI2tSNAME \D.CkZ YI\j.
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL❑ RESIDENTIAL a
PRINT
CLEARLY NEW:0 RENOVATION:CO REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO❑
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/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
LAVATORY
ROOF DRAIN
SHOWER STALL I
I SERVICE MOP SINK
TOILET
URINAL R--E C E- V C 8
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES WATER PIPING MM1 O 7 202k
OTHER
_ r - _ _ -
g LI OL0 nPP.ORT.ENT ^I
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 7.1 NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY M 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
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
LU I hereby certify that all of the details and information I have submitted or entered regarding this application am 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 Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �gg++
PLUMBER'S NAME JtAi .i SM>=r� LICENSE# i— SIGNATURE
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MP 0 JP® CORPORATION❑# PARTNERSHI ❑# LLC❑#
COMPANY NAME �S ?ux,it;c1J& ADDRESS '"-TAUT O SCETL V 11-0
CITY OSI ELWZU,.E @ STATE MA ZIP 02L.5S TEL V57-1,78-
FAX CELL EMAIL -❑t'SPL.Latn3T1-1C5KUALQ GM4 ,CAM
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PLUMBLIG TION NOTES BELOW FOR OFFICE USE ONLY
FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT. 0 D
•••••=•• ••..-•••••'..Arr.m• ,J. 2
FEE: $ PERMIT
PLAN REVIEW NOTES
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