HomeMy WebLinkAboutBLDP-24-231 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
• CITY' G w,'ch MA DATE 3-oc- 1-\ PERMIT# RI-0P-2y-'L3/
JOBSITE ADDRESS 3 "lbw,v Ica Ass_ OWNERS NAME
POWNER ADDRESS 3 Un WO RK, TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL❑ RESIDENTIAL III
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:® PLANS SUBMITTED:YES 0 NO 0
FIXTURES 1. FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14—
BATHTUB I
CROSS CONNECTION DEVICE --
DEDICATED SPECIAL WASTE SYSTEM --,
DEDICATED GAS/OIL/SAND SYSTEM -
DEDICATED GREASE SYSTEM 1
DEDICATED GRAY WATER SYSTEM -
DEDICATED WATER RECYCLE SYSTEM -
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER -
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK -
LAVATORY 1 .
ROOF DRAIN —,
SHOWER STALL R E CIE:1 VL E'8---
SERVICE/MOP SINK
TOILET t n��nn�
URINAL - " 1RPfR0 6 CULT -
WASHING MACHINE CONNECTION -
i WATER HEATER ALL TYPES BUI_UiNGDEFAR1 ME',
WATER PIPING - -a, -
OTHER - -
-
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ig NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUIY INSURANCE POUCY NI' 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 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
1-1.1 I hereby certify that all of the details and information I have submitted or entered regarding this application are t end accurate to the b my 6fknowledge
and that all plumbing work and installations performed under the permit issued for this application will be in nce with all P ' nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAMECtve's Vt.-KAvei LICENSE#►?381 . SIGNATURE
MP JP 0 CORPORATION 0# PARTNERSHIP❑.# LLC 0#
COMPANY NAME CZ MIAVO1 c k"N ADDRESS D70 Ak^'S‘likk Y19.43c,c0
CITY MCi%\lR.t c, STATEMpI ZIP -kq TEL
FAX CELL Sol7''S S) EMAIL C1'hp1Vi-1C3 yghoo 4G►rn
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