HomeMy WebLinkAboutBLDP-24-637 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
-_�— CITY )6(e 00.4 vor4 MA DATE -7 2`f 24( PERMIT# SLOP 2N_(4,77
JOBSITE ADDRESS I 2)O CC k / o,d rd OWNER'S NAME I`eV; 11 Van
OWNER ADDRESS S A ME TEL S d8-�3 7"755'3 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO❑
FIXTURES 7 FLOOR-, BSM 1 2 3 4 5 6 7 6 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 J
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
_ KITCHEN SINK
LAVATORY •
ROOF DRAIN I H D
SHOWER STALL
SERVICE/MOP SINK _
TOILET J
URINAL
WASHING MACHINE CONNECTION / 3UILDNGUEF'AR1MENI —
WATER HEATER ALL TYPES -i --
WATER PIPING //��
OTHER Po+ t;I(er
ICE /+oeK �p /
7 INSURANCE COVERAGE:
I haVe a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YEW NO❑
IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY INSURANCE POLICY`tF+t 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 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
L-LI I hereby certify that all of the details and Information I have submitted or entered regarding this application am true and accurate to the best of my knowledge
and that at plumbing work and Installations performed under the permit issued for this pplication will I jp co ce with Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. QJ`JJ(
PLUMBER'S NAME-Da' M C Cr JS$t exLICENSE# Z/(o'y SIGNATURE
MP INt JP 9 CORPORATION 0# PARTNERSHIP 0#p LLC❑#
COMPANY NAME ApY I nt PLU m B e a ADDRESS f C� O 09-p352.o
CITY 2b V Y I S `O CA STATE Y-`L` ZIP 02pt'o 3 S TEL_LO, -3 16- �e 3
FAX CELL EMAIL Cktl.tre @cave ThtPlumber,(Om.
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT l (l
FEE: $ PERMIT #
PLAN REVIEW NOTES