HomeMy WebLinkAboutBLDP-23-10689 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
1 0 ,, TI'f . ` MA DATE A� iff/ �'3 PERMIT# I L P 23--10 4.,79
1' OBS__. ar/q C sst°� L�✓` JOBSITE�D• SS 1 OWNER'S NAME /U+eY/✓ C�rA rry
JUN°OVVNER3AD RE.S TEL FAX
EN
Q:- CI d4CYr_TY•E COMMERCIAL �EDDUCATIONAL D RESIDENTIALLY/
' ARLY NEW:❑ RENOVATION:❑ REPLACEMENT:/ PLANS SUBMITTED:YES 0 NO❑
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 144
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 •
DRINKING FOUNTAIN .
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR) H
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE 1 MOP SINK
I TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING 1_ _
OTHER!
Qo, cr
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Q' NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY L�J OTHER TYPE OF INDEMNITY 0 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.
s CHECK ONE ONLY: OWNER❑ AGENT❑
SIGNATURE OF OWNER OR AGENT
4.1 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 p' n=with all P 'nent provision of the
Massachusetts State Plumbic g Code aid Chapter 142 of the General Laws.
PLUMBERS NAME/, LICENSE#ay 3��. SIGNATURE
MP 0 JP L�R I p/ J CORPORATION 0# PARTNERSHIP❑.#/� LLC 0#
COMPANY�NAME rx u S f C Ot nS v �:77-, A ADDRESS S�� 0 i� + 5 Rif rc /2Q
CITY 0006 STATE/YI ZIP 6dG1 TEL
FAX CELL�O`/3C3 5-1/7I EMAIL W,/r S:.6 I C/ Corr,
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
I