HomeMy WebLinkAboutBLDP-24-777 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
;-, CITY )04rrrs00�1,-, MA DATE 9/1O/2-"I PERMIT#QGOP-ZN- .777
JOBSITE ADDRESS 133 Ma7E(„„r,, TQ rf�� OWNERS NAME Ecrc,0, GcL a eke.
POWNER ADDRESS '33 l'rr � al\�.,1,s N.u. TEL(GI1) 87S"--(?tyl FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL,.
PRINT
CLEARLY NEWX RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES❑ NO 0
FIXTURES 7 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 0
BATHTUB _ _
CROSS CONNECTION DEVICE _
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM
Il
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
III
DRINKING FOUNTAIN _
FOOD DISPOSER PtaI 11i 1IL Nil
FLOOR/AREA DRAIN { -
INTERCEPTOR(INTERIOR) M�I
, _
KITCHEN SINK _ • O 71r ,'.■
LAVATORY
ROOF DRAIN pPA111111111.11
SHOWER STALL ' _gym _
SERVICE/MOP SINK
TOILET
I URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES x
WATER PIPING _
OTHER
01 L 1,4 9L-s C'onzvers ,a,r)
PS - 'Q .J C.a.,ti,L'r _
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO 0 I
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY, 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 requirement.
CHECK ONE ONLY: OWNER 0 AGENT 0
Z SIGNATURE OF OWNER OR AGENT
"+:! 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. ElPr
PLUMBER'S NAME R6\eGr\ ¶ ,cw& Ve-gC LICENSE#133 gel. SIGNATURE
MP"Y, JP❑ O R A CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME CA b Mev\-..G.,rJ I.c.a(- ADDRESS WI— ( iv.l,3o RN
CITY GYa.N5-\c STATE R-' ZIP O2912-0 TEL
FAX 'CELL `kg('- 719 S EMAIL N -a >s girl- iris cj,v s ',L-'CJ -e\
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