HomeMy WebLinkAboutBLDP-24-252 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY Ske v t.I,3 (o.r-I'-' MA DATE 31 13122*-1 PERMIT# A L i0 P-2`1-tea
JOBSITE ADDRESS 11/4.1_40 -1 S 'sr- OWNER'S NAME at.L_
POWNER ADDRESS ° TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW:0 RENOVATION:la.' REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO 0
FIXTURES 1 FLOOR-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB I
CROSS CONNECTION DEVICE
-
DEDICATED SPECIAL WASTE SYSTEM ----1
DEDICATED GASIOILISAND SYSTEM 1
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR) -
KRCHEN SINK 1
LAVATORY '� •
ROOF DRAIN
SHOWER STALL I _
SERVICE 1 MOP SINK � ('
TOILET .. _ _..1
URINAL _
WASHING MACHINE CONNECTION I1 -
WATER HEATER ALL TYPES _
WATER PIPING BUILDING DEPARTMENT
OTHER "v
I
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ffY NO 0
IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POUCY IRr 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.
CHECK ONE ONLY: OWNER❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
L:l 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 Plumbing Code and Chapter 142 of the General Laws. W
PLUMBER'S NAME Way run g.0 r.re\ LICENSE# t SI ATURE
MP JP 0 CORPORATION 0# PARTNERSHIP Q# LLC 0#COMPANY NAME Qo I ca,1 P€-t+ ADDRESS lc'& u . -011- CT� tals
CITY µar1..e c+c___ STATENIA- ZIP c7 tc`c'V TEL s0`ts 6Z-t-'j,,s-vc-,
FAX CELL EMAILC&sr eAAQCa .. u.L'?�g„-.nit,cmr. ,
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT I I L I
FEE: $ PERMIT #
PLAN REVIEW NOTES