HomeMy WebLinkAboutBLDP-20-004931 r(16
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY vJers Yek.rvna,)St(,. MA DATE�7 PERMIT# P-AO-01/9$1
JOBSITE ADDRESS 130 CIe'lrfCJ� Kc, OWNER'S NAME 10 12 TCXL°1 Ca
OWNER ADDRESS 11,z act TEL(SAC 9aa. I3r FAX N/4
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:k] REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO❑
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
DEDICATED GASIOIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER RECEIVE
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN FEB')f 20
INTERCEPTOR(INTERIOR) (T)
KITCHEN SINK
LAVATORY aI"
i3U GOING 5CP T
ROOF DRAIN �ar
SHOWER STALL
SERVICE I 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, NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY INSURANCE POUCY[' OTHER TYPE OF INDEMNITY❑ 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❑ AGENT❑
SIGNATURE OF OWNER OR AGENT
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 compl'a wit II Pe'nen vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ���
PLUMBER'S NAME I� Q-0 .n1 CoLQ.W kA UCENSE# O cl 36 6'-,3SIGNATU E
MP❑ JP Ri CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME n1O*P Q.o vcty Pluvv,Iorvi 0441ADDRESS R P.2 avv;. Il'u.KiP¢' 60/i3J
CITY 113rew.S40✓ STATE fli‘th ZIP 0243I TEL RBS U393
FAX IN/14. CELL( ) RRS-y393 EMAIL YV1rr'tYrAorvo.v.,r`larv�Yvy9?9a c@J� prnl/j ra v�
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Bo(,{� �t �I(il l/��}� � '["G v� Yes No
J ci• � /` (�— THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
iiVkA re a A
T t/L ( I loot4 mom FEE: $ PERMIT t�
P-??7- d t(�L/ 3//g/ 6
PLAN REVIEW NOTES
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