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HomeMy WebLinkAboutBLDP-19-002585 ~ ' � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITYCX jc OCA4,-. MA DATE /0 499!/( PERMIT# P''/9 .7, -em JOBSfTEADDRESS ry W/ 111 III�iarf LA/ OWNERS NAME\ r'Vf1hi4 At-'y POWNER ADDRESS al../ vlhcfr F LA/✓o rtnOd pftL FAX —AX TYPE OR OCCUPANCY TYPE COMM CIAL 0 EDUCATIONAL 0 RESIDENTIAL L�' PRINT CLEARLY NEW:❑ RENOVATION: REPLACEMENT:0 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 _ DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM _ DEDICATED WATER RECYCLE SYSTEM i DISHWASHER • DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN _ INTERCEPTOR(INTERIOR) - t Lu D- _ KITCHEN SINK I LAVATORY > I - ROOF DRAIN I I I r r 1 _ SHOWER STALL X' SERVICE/MOP SINK DEPART EN r TOILET >C URINAL WASHING MACHINE CONNECTION x WATER HEATER ALL TYPES WATER PIPING )c.- OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ErNO 0 IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LLABIUTY 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 ' Massachusetts General Laws,and that my signature on this permit application waives this requirement. 2 CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT L-U I hereby certify that all of the details and information I have submitted or entered regarding this application true d accurate to the best of my Imowledge and that at plumbing work and installations performed under the permit issued for this application will be i ompria a with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBERS NAME LICENSE# 2 SIGNATURE MP❑ JP CORPORATION❑# °�°�PARTNE SHIP Q# LLC❑# COMPANY NAME pe IU✓yv�lyrq,�NJ I ADDRESS I($ [ l� �'1',l' CITY BVQ.1/A`CQ STATE 61OI ZIP ©ab3r! TEL77Y'5-7$ z.2- FAX CELL EMAIL TWIOI6 4 O 61ey— ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No /F )i ) / 0)/( THIS APPLICATION SERVES AS THE PERMIT El t / 4-- /11 / 2 /1 1 C FEE: $ PERMIT # r )- PLAN REVIEW NOTES /k1/ ' 5- /V O r g y A5g/f/ r/c4;:f5 ♦