HomeMy WebLinkAboutBLDP-24-80 •
s'\ MA�SfSACHUSETTSUNIF�ORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
U. 7 CITY AS ` .4 4-1.6 -1-1 MA DATE I/0 3/a y PERMIT# 2
rX
JOBSITE ADDRESS R 41111`t°YL S !e 0 OWNERS NAME/14/1C.G Pc -. -r1
P OWNER ADDRESS SAvu-- TEL-7$177S 6)%FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 115
PRINT
CLEARLY NEW:❑ RENOVATION:9y REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO 0
FIXTURES 1 FLOOR-' BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14-
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 '/4,
DRINKING FOUNTAIN
•
FOOD DISPOSER r ice.
FLOOR/AREA DRAIN
• I
INTERCEPTOR(INTERIOR) JAN 23 71174 J 1
/�-KITCHEN SINK
LAVATORY •
ROOF DRAIN ttyui�DINC le-Pnw,T00FNT t
SHOWER STALL 'Y
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING 1- - "
OTHER -
I
I
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES B NO 0
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
1 li
Massachusetts General Laws, nd that y sign ture on this permit application waives this requirement.
CHECK ONE ONLY: OWNER❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
L:I 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�th all P nent p vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE#13 75's SIGNATURE
MP JP❑ CORPORATION❑## PARTNERSHIP❑.# LLLL7JC❑7#
COMPANY NAME MAVLL0 i6d9 pi-`1 ADDRESS a62- C. ODL 173
CITY CC---('t -4/t_ STATES ZIP ��d YYC. /f TEL c05S� a
l4'f 03,)
rr(�.
FAX CELL SA EMAIL t /Zg' dC4- 4/3®61414//ICOY'
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT fl ❑
FEE: $ PERMIT #
PLAN REVIEW NOTES
I
A