HomeMy WebLinkAboutBLDP-24-397 0_aD
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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__ s� CITY ra /r)f� MA DATE i 1 fQ PERMIT# DP"141-397
JOBSITE ADDRESS o2 d /- ✓a/1 j I^JaC l .- OWNS 'S NAME Ld LA.S
OWNER ADDRESS 1:). @,D v' ,, TE S`Q 6-)?6,./ VC/ea
TYPE OR OCCUPANCY TYPE a COMMERCIAL►' , EDUCATIONAL�"� ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:0 RENOVATIO<J REPLACEMENT:❑ PLANS SUBMITTED:YES[4/NO 0
FIXTURES 1 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/OWSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER / •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY • �3 E f` F-I F
ROOF DRAIN �T _
SHOWER STALL p
SERVICE I MOP SINK APR• ZU1't -
TOILET • _ _
URINAL _�UILDIVG DE PARTVIENT
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. YESX NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY g OTHER TYPE OF INDEMNITY❑ BOND 0
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: OWNET4 AGENT❑
SIGNA 0 OWNER OR AGE
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 In corn once with all Pertinent ovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. v-
PLUMBER'S NAME (J I/l frrrn ,7".4 thd°,1 JCENSE 07 p 9\2 NA E
MP❑ JP CORPORATIONl 0# PARTNERSHIP❑.# LLC❑#
COMPANY NAME C'' \ ✓<P/tJvYt 5•tiC �//e ADDRESS d-�a /C/h Lo an c' C/_-C
CITY J,)'I�f/e-c l STATE 9.77 ZIP O.Z 4,6 7 TEL
FAX CELL b J Yd/ —L7//'G EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT I
FEE: $ PERMIT #
PLAN REVIEW NOTES