HomeMy WebLinkAboutBLDP-24-842 r MASSACHUS TTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
_L , CITY r OI/ MA DATE( t' 0,0a1 PERMIT# af-DY-24 $ci
JOBSITEADDRESS ( OWNER'S NAMED W4 IIf
P OWNER ADDRESS 59rnt. TEL3O 2?t-Y Y FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL-91
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO/A.
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 GASIOILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM _
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) _
KITCHEN SINK
I DRY ROOF ` E I
ROOF DRAIN _
SHOWER STALL 1 _
SERVICE I MOP SINK - [KT
;ITOILET
I URINAL
WASHING MACHINE CONNECTION 'BUILISING L EPARTMEN T
WATER HEATER ALL TYPES --,--
WATER PIPING
OTHER
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INSURANCE COVERAGE:
I I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YE NO 0
IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 321 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement.
I CHECK ONE ONLY: OWNER 0 AGENT❑
Z SIGNATURE OF OWNER OR AGENT
L1.1 I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accur o the best of my knowledge
and that all plumbing work and installations performed under the permit Issued for this application will be in co n� erlinent provision of the
Massachusetts State Plumbing Code and
hapter 142 of the General Laws.
•
PLUMBER'S NAME/sef �" p
1ft l LICENSE#�/�I . �/ SIGNATURE
MPCOMP Y NAME ���l VolI�OM �CORPORATION 0# PARTNERSHIP,/ /M ❑# LLC❑#
j� J� G1 --t: l yy� ADDRESS /g� 7 L�GYa AM-- �c y,G 7/
CITY /lTc th CIA \/ STATE///A ZIP O�ys ] nTELL,/J-%O/'7/(�-8N3
FAX CELL ,SQIYI.. EMAIL/2rMj/lASS>Ict lutmo1/ (oyil
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