HomeMy WebLinkAboutBLDP-18-000148 .}1\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Hit, � CITY /4tmou' Y\/ gefM/AATE 7lI l (l'7 PERMIT#ALD//$-a*/
JOBSITE ADDRESS it'? CC2/h2,att Rai i OWNER'S NAME z a KC Gy le
Pk
OWNER ADDRESS TEL 1-1),-0 u rW TEL 508"7.37-5?S(FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL'
PRINT _
CLEARLY NEW:❑ RENOVATION:7��{ REPLACEMENT: NM. PLANS SUBMITTED:YES 0 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/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM _
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER /
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN _
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY 2,
ROOF DRAIN _
SHOWER STALL
i SERVICE/MOP SINK
I TOILET a,
URINAL _
WASHING MACHINE CONNECTION
WATER
PIPINGHEATER ALL TYPES ` Q/ ��
WATER PIPING �,// `r�
OTHER i JUL 1 L 2011
i
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 TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY,' 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
t Massachusetts General Laws,and that my signature on this permit application waives this requirement.
`x CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
Ltl 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 compli�eril nt provi'o f the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. CC��
PLUMBER'S NAME LICENSE# SIGNATUR
MP 0 JP 0 CORPPO�ORATION 0# PARTNERSHIP❑# LLC 0#
COMPANY NAME �f Ld /_r ADDRESS 30 /yfy � b�
CITY C'A i9 a th STATE 41A ZIP O 4)-6 7 / TEL
FAX CELL6-08 7 RN EMAIL T6M1,/ -cc(3 P."AiAK.,Goner
1.-Rlf 4' //D•az)
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0
FEE: $ PERMIT #
PLAN REVIEW NOTES ire
0 Alt/
1 y '