HomeMy WebLinkAboutBLDP-24-428 MASSACHUSETTSS UNIFORM
�T/1 APPLICATION FOR A PERMIT
�JTO PERFORM PLUMBING WORK
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CITY `f ,vr(J U MA DATE 5 `/L PERMIT# l(40P_ ZN-N29
JOBSITE ADDRESS/j2 f e 7 4-6`,Al2(2 i OWNERS NAME •
POWNER ADDRESS 2 J ( //,/ iZ OATtL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUC IONAL❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT: PLANS SUBMITTED:YES 0 NO
FIXTURES 1 FLOOR-, aSM 1 2 3 4 5 6 7 8 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 I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK R ._ r 0
LAVATORY c. . �_
ROOF DRAIN
SHOWER STALL I AY I I
SERVICE/MOP SINK
TOILET I BUILDING EPA
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
I WATER PIPING
OTHER tli/-
P- MitietSe
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 TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILPIY INSURANCE POUCY 0 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
L:I 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 compile with all Pertinent provision of the
Massachusetts State Plu ing Coddle and Chapter 142 of the General Laws.
PLUMBERS NAME I A f 1iirLi/-V?O j OVtA1FNSE#(54/Cl SIGNATURE
MP «� ./'CORPORATION 0# PARTNERSHIP❑.# �r LLC❑#
COMPANYY N ME �6�A� ( ���Mk-
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CITY l t T/ STATE MIT/ ZIP 3 15�7 7 d 99 3
FAX CELL EMAI /Pt dtl0
70 — ef -41 3b 3
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERM
IT #
PLAN REVIEW NOTES
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