HomeMy WebLinkAboutBLDP-24-690 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
1 CITY Y/4Rmo ^ r�S0 .tt-1 MA DATE Q^ra-ay PERMIT#ULDP 2-1'-690
JOBSITE ADDRESS 9 GhRRIeS CTree+ OWNERS NAME �TR Z'Eta
OWNER ADDRESS aQ C�P.RIe- S+rk+ TEL6bsn' y-(06a, FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL-
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:' - PLANS SUBMITTED:YES❑ NO❑
FIXTURES? 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 •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK /
LAVATORY •
ROOF DRAIN
SHOWER STALL F 9
SERVICE/MOP SINK
TOILET j URINAL T 2024
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES at ncr'CEPARTMENT
WATER PIPING / By
OTHER
I _
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Jg NO 0
IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSUR4NCE POLICY 4- 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: OWNER❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
LLI 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 teliance-with all P provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME GR E 6o KY cc IcC LICENSE#a G?g4. SIGNATURE
MP❑ JP I CORPORATION 0# PARTNERSHIP❑.# LLC❑# D aA
COMPANY NAME 6:reao4yc )FcV(r.,e4r41,-.5rtrccADDRESS C(I 5P et8e,e L,/}-fie
CITY w }l�5rm•..1-11 STATE mR ZIP 0e6�3 TECT°0 -7OQ'-1"`/
FAX 6 CELL Co8 f1/4(3Y EMAIL Selfeg � e yn-hov.C�,
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT I l
FEE: $ PERMIT #
PLAN REVIEW NOTES