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Home My WebLink AboutBLDP-21-004454 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �, II CITY [ RMOUTH MA DATE 2/5/21 PERMIT# BLDP-21-004454 W " JOBSITE ADDRESS 194 BERRY AVE OWNER'S NAME WHITE RICHARD A P OWNER ADDRESS WHITE JOAN P 6189 SHOREWOOD COURT LISLE, IL 60532 TEL TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YESE NO❑ FIXTURES -'f FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/S.AND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTE DISHWASHER 1 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 2 LAVATORY 3 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 3 URINAL WASHING MACHINE CONNECTION WATER HEATER WATER PIPING OTHER OTHER DESCRIPTION: 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 POLICY❑ 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. 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 compliance with all Pertinent provision of the Massachusetts State Plumb ng Code and Chapter 142 of the General Laws. PLUMBERS NAME Adam Larsen LICENSE r750 SIGNATURE MP ❑ JP ❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑# COMPANY NAME ADAM LARSEN ADDRESS 8 FARNHAM ST CITY BOSTON STATE MA -I ZIP 021192908 TEL FAX CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVE AS THE PERMIT 1:1 ❑ FEES E PERMIT M PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK =: _ 7i CITY Gc�S `i`'�> MA DATE ( I�Z 1?A PERMIT# - 1 +)0`f ^�~ JOBSITE ADDRESS 1 CO. ( ,9 VC`t '�� ' • OWNER'S NAME C LLt 4` ' POWNER ADDRESS I TEL �J l TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:Q REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 5 7 8 9 10 11 12 13 14 BATHTUB t _ CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM _ _ DEDICATED GREASE SYSTEM . DEDICATED GRAY WATER SYSTEM _ DEDICATED WATER RECYCLE SYSTEM . DISHWASHER t _ DRINKING FOUNTAIN FOOD DISPOSER - FLOOR 1 AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK t 1. LAVATORY _( • p1 ROOF DRAIN SHOWER STALL t SERVICE 1 MOP SINK TOILET t 0 F _ 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 MG. qR 1O2. r ;- t IV le n IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOVI '—I q I LIABILITY INSURANCE POLICY ❑ OTHER TYPE OF INDEMNITY ❑ BOND Elf JAN �� .] OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required,41 M ISstalrviENT Massachusetts General Laws,and that my signature on this permit application waives this requirement. i by _ __ CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT 1 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. f• - PLUMBER'S NAME_ ethivs.. t,e3Lccje LICENSE# ,i cf' SIGNATURE MP❑ JP is CORPORATION❑# PARTNERSHIPP❑# II LLC❑# COMPANY NAME WlbfL4fin`( (\,---)lnn�\i ADDRESS T.A. L.Ot d F 6 • • CITY /V (/V Ifti l 1/tw‘- STATE VIM ZIP 0 c v TEL FAX CELL _1 qt( ) .6 '13•MAIL f N-) 4e„,r,,6 C3 L (c)f'-,.. 3.J