HomeMy WebLinkAboutBLDP-16-005573 1
ti O . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
"`_ ' �.{' ,N,o '17\ U-l4-— 1 b PERMIT#f1-Oi/li 006S"7/
ۥ==1a_ = CITY s MA DATE
' ``l C 41o.SWE�DDRE S 4 , iJon.* K`ilk- IZ OWNER'S NAME l�'gVs&11 SRr\1pc:4)4v
pDDIRES TEL FAX
APR 1°�"" io I
TY OR _OCCUPANCYTYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTI3t
pRINTINGDLF,.- i
:L°EARLY-N€W:(TI _ RENOVATION: REPLACEMENT v Q PLANS SUBMITTED:YES 0 NCV
FIXTURES 2 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/OIVSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN T
INTERCEPTOR(INTERIOR) _
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL _ _
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION _
WATER HEATER ALL TYPES
WATER PIPING i ( _
OTHER .
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YE m NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW J�
UABIUTY INSURANCE POUCY 0 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.
CHECK ONE ONLY: OWNER 0 AGENT 0
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 allirier7 ''on of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME f`(1‘_T ,0 rv` ,LICENSE# Z-\1 3 SIGNATURE
Mkti(_. JP 0 n RPORAATION 0# PARTNERSHIP Q# LLC 0#
COMPANY NAME l_�;I�v'-\ ' +-NA T ADDRESS .--?'O �7` �
(�3� —� 11
CITY • \VGA Ov'N'� STATE�� ZIP 1-�!F-,�0 TEL e8`11 Q 41`Y
FAX CELL S+M►s-e-- EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No rift �- � r % S. to c Gd f
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ � LIco ����ivil cgs
FEE: $ PERMIT #
PLAN REVIEW NOTES
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