HomeMy WebLinkAboutBLDP-24-622 MASSACHUSETTS UNIFOR APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK( r
—=0.— CITY ►A✓C5 / l or.,)/ MA DATE PERMIT# Ala—a�
JOBSITE ADDRESS 4 / ' Ca'✓L o!i�,7 OWNERS NAME ICGi?A le01�Qf1
POWNER ADDRESS ( TEL FAX
TYPE OR OCCUPANCY TYPE COMMERC 0 EDUCATIONAL 0 RESIDENTIAL P**---
PRINT
CLEARLY NEW:❑ RENOVATION: 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 _
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM /
DISHWASHER
DRINKING FOUNTAIN _ —_.1
FOOD DISPOSER
FLOOR I AREA DRAIN �-g
INTERCEPTOR(INTERIOR) / I r� � 0
KITCHEN SINK f
LAVATORY • a 7 Mit
ROOF DRAIN
SHOWER STALL ____
SERVICE/MOP SINK 7euUiLc irvm:.' / K MLNr
-14 TOILET
- - - _
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING _
OTHER _
i
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE 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
i Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE ONLY: OWNER❑ AGENT❑
SIGNATURE OF OWNER OR AGENT
LU I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the st of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in rep lance all P provision of the
Massachusetts State Plammbs Code and 9hapter 1 2 of the General Laws.
PLUMBER' NAME DO �j I'0� LICENSE# kg-fa SIGNATURE
MP .----
PLUMBER' 0 (� I 1 p,,, Jfr, CORPORATION 0# PARTNERSHIP Q# / /� LLC 0#
COMPANY NAME Ud0 5 rift-1'45 ADDRESS c2 n Ian( &cs R1 id. pP
CITY Oe11n f S 7 �^STATEE AR ZIP TEL
FAX CEU/7r 3. 3 .F0( EMAIL t I r° 5S$ f /2.1 ,C!1'V‘
. (.1ah
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