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HomeMy WebLinkAboutBLDP-18-000138 . y MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK WrCITY TGu"m�''r!�6i MA DATE 7 �a / PERMIT# �+��� ",�a,,. . L L /� �- JOBSITE ADDRESS /// ' / /�/ 0/1 OWNER'S NAME edi I �J e-;el POWNER ADDRESS 3010 '26tU,e-� s Jana- © �TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL g-- PRINT CLEARLY NEW:❑ RENOVATION: ❑ 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 GAS/OIL/SAND SYSTEM _ DEDICATED GREASE SYSTEM _ DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER _ 1.7\I)4 4,..„. --'')- _ _ _ DRINKING FOUNTAIN _ _ FOOD DISPOSER _ FLOOR 1 AREA DRAIN _ INTERCEPTOR(INTERIOR) KITCHEN SINK .la- 1 O �� -1../ k \,,,..., LAVATORY • WI-V-1A _ q * SHHOWEER STALL 'vT V 1 SERVICE/MOP SINK TOILET _ URINAL WASHING MACHINE CONNECTION _ WATER HEATER ALL TYPES 1.------ _ WATER PIPING OTHER I 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 TYRE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [2-- OTHER TYPE OF INDEMNITY ❑ BOND D 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 `mil I hereby certify that all of the details and information I have submitted or entered regarding this application are true d accur to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co c all Pertin nt provision of the Massachusetts State Plumbing //Code and Chapter 142 of the General Laws. PLUMBERS NAME /C Gi 74ti4 r•..-.I/h7 LICENSE# //lot SIGNATURE MP 11--' -JP❑ e /iCORPORATION❑# PARTNERSHIP .# / LLC❑�# COMPANY NAME 7-0---:44 tifrt ADDRESS '4/ �n� j AV/ /C L CITY S.-Cc/144 4 STATER ZIP 33-2 TEL Nraycj 7/936' FAX CELL EMAIL ��— J 6) ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No /: zp -1 . j��� / /q/' THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ /„/ /0 FEE: $ PERMIT ft / .71__ Cam" PLAN REVIEW NOTES