HomeMy WebLinkAboutBLDP-24-538 MASSACHUSETTS��/ UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
e= CITY 4I m01 n MA DATE -7' 2/ PERMIT# al-OP-24- 5 32
JOBSITE ADDRESS 7 MfNJ lArd 5 OWNERS NAME Vp 014 5
POWNER ADDRESS •=i.,y.t42.. TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL 0—
PRINT
CLEARLY NEW:❑ RENOVATION:p REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO 0
FIXTURES 1 FLOOR-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB / /
CROSS CONNECTION DEVICE _'� -
DEDICATED SPECIAL WASTE SYSTEM G
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM _ -/�'
DEDICATED GRAY WATER SYSTEM JU. 0
DEDICATED WATER RECYCLE SYSTEM I
DISHWASHER J. 'aUILDIN0 1
DRINKING FOUNTAIN MEN,
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK /
LAVATORY / / •
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET / /
URINAL
WASHING MACHINE CONNECTION /
WATER HEATER ALL TYPES /
WATER PIPING
OTHER _
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES is NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE F 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
l' Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER❑ AGENT❑
SIGNATURE OF OWNER OR AGENT
L`J 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 Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE#/07 'y SIG URE
MP JP❑ �[' / CORPORATION 0# PARTNERSHIP❑# LLC 0#
C MPANY NAME i / AM7i',,ifibl i.,75 ADDRESS /Z 1-J4/) 62s44) /2D
CITY ---/X2/9/)/S STATE,/714- ZIP 02 Se."' TEL'Cot-3/.1- 'V0"
FAX CELL'/--237-97.07 EMAIL iG FAI4ye_/` ea Alai/.coi
ROUGH PLUMBING INS
PECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No -
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT #
PLAN REVIEW NOTES