HomeMy WebLinkAboutBLDP-24-110 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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€zla=a0 CITY Yargle../A_ pp MA DATE ,—' PERMIT#&LOP'2°r-1/O
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JOBSITE ADDRESS e215- RI- �q `� �J �j..�
p`C� OWNER'S NAME �yl..te (�'LCB�/
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 21/ EDUCATIONAL 0 RESIDENTIAL❑
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:Q/ PLANS SUBMITTED: YES 0 NO❑
FIXTURES 7. 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 i
DRINKING FOUNTAIN -
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
•TOILET
/MOP SINK i�R F E t _ G
URINAL l . __
WASHING MACHINE CONNECTION - FEB 01 7112
WATER HEATER ALL TYPES
WATER PIPING
fyUILDING DE.A t OTHER ..0 El _r_
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO 0
IF YOU CHECKED YES.PLEASE INDICATE THE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does n surance coverage required by Chapter 142 of the
J Mag c r efts General Laws,and that my signature • rmit application waives this requirement.
r CHECK ONE ONLY: OWNER ID AGENT 0
SIGNATURE OWNER OR AGENT
LU I hereby certify that all of the details and information I have submitted or entered regarding this appliraIon are 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 lance with a ertinent provision of the
Massachusetts Stale Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME C,LriS ?oboe... LICENSE# M. 33191 IGNATURE
MP❑ JP LK CORPORATION 0# PARTNERSHIP❑.# LLC 0#
COMPANY NAME N-C- ? 1-i C ADDRESS c.I s ,t 7 pJ_
CITY yy4nn\S STATEII'Le, ZIP 0.26a\ TEL
FAX CELL '7)L' g 3'6 CO%1 EMAIL(ht.a(r.w har.340:y M 4:i.(pe.
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