HomeMy WebLinkAboutBLDP-23-8526 (2) MASSACHUSETTSf ,,� L UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBINGl� WORK
�_--,9,� I/ CITY LU. -e i// .7 otT,7 d hMA DATE 5 `�Z PERMIT#�/ V" Z 3-s.f„
JOBSITEADDRESS 1(Sba �Uf LA'-r-dl y�1712,4V NER'SNAME 6A� ell
POW C`1J7 OWNER ADDRESS a ,iZ i47-Cr TEL'79�-('16tr'C1�t FAX_
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCA L 0 RESIDENTIAL 0
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED:YES❑ NO 0
FIXTURES T 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 R ('- F I V G
DRINKING FOUNTAIN ��� .� 7q
FOOD DISPOSER 1 Y"J _
FLOOR I AREA DRAIN H 1
INTERCEPTOR(INTERIOR)
KITCHEN SINK Elul DING utr-n-1TME T
LAVATORY • . L ---
ROOF DRAIN _ _
SHOWER STALL
SERVICE 1 MOP SINK
TOILET I i I
j 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 MGL Ch.142. YES NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILI Y 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
1 Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE ONLY: OWNER❑ AGENT❑
SIGNATURE OF OWNER OR AGENT
L-1 I hereby certify that all of the details and information I have submitted or entered regarding this application are hue 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 co pli nce with all P nent provision of the
Massachusetts State Plumbing Code and Cpapter 142 of the General Laws. „/ �-
PLUMBER'S NAME (jt;Ih (AA l 5O!✓ LICENSE#Pi�s c `'SIGNATURE
MP❑ JP 0 ll I / I CORPORATION� 0# PARTNERSHIP❑./# /�LLC❑#
COMPANY NAME P tifrMb,n� `hest r S ADDRESS �(J 0(I� SS 1Cl,cf PuD
CITY I uvv S ) STATE Al Pr- ZIP G1-t,1-- TEL/ /
FAX CELL 77`-/ 3r3 gj'Y71 EMAIL i.✓t(141 SD t CCo✓iA,Cc m
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