HomeMy WebLinkAboutBLDP-24-435 /10.0-
MASSAC USETTS UNIFORM APPLICATION FOR A P T TO PERFORM PLUMBING WORK
'.-er- CITY O MA DATE Z PERMIT* t'I
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JOBSITE ADDRESS OWNERS NAME 257Y7k,VX1sOV 1311Z/
POWNER ADDRESS (1tZZ /36C - Z FAX(J-,
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAfid RESIDENTIAL Ita"
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CLEARLY NEW:0 RENOVATION:'% REPLACEMENT:0 PLANS SUBMITTED:YES U, 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
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK /
LAVATORY 7_ / _ • -
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK / _ 1_ , C C p-,is j y -
TOILET Z /
URINAL MP6 -I
WASHING MACHINE CONNECTION ri _
WATER HEATER ALL TYPES 6t513 i, ✓ ■ ut�ARr
WATERPIPING e M:Nr -
OTHER //t('.? -C<� /)....., / J
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES A NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY 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
J Massachusetts General Laws,and that my signature on this permit application waives this requiremenL
CHECK ONE ONLY: OWNER 0 AGENT❑
SIGNATURE OF OWNER OR AGENT
L 1 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 all Pertinent provision of the
Massachusetts State Plumbin Code and Chapterha _142 of the G eral Laws. I C,/'�'/ f�
PLUMBER'S NAME Mr Z°t- I"t W 1-i LICENSE# 6 O! SI N TURE c—
MP❑ Jq51]. l '7 '/ CORPORATION❑# Pro P` PARTNERSHIP 0..#' / /LLC❑#
COMPANY NAME I"L [`I�Q i- 1 6 1L - -^ ADDRESS .�7 ri--. 41e 14
CITY 6 Gt^/:L STATE I�M}- ZIP (J 74 D/ TEL 7?Y >/d %/d '
FAX ` CELL VVV___ ��' EMAIL L 1)/ •//An.
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT #
PLAN REVIEW NOTES