HomeMy WebLinkAboutBLDP-24-735 MASSACHUSETTS UNIFORM APPLICATION FOR A ERMIT TO PERFORM PLUMBING WORK
•—aw. CITY �• q I-”,,a Jai MA DATE PERMIT# B L 0 P-Z t-7 3 S
JOBSITE ADDRESS s7fq/4�� Z2 OWNER'S NAME 1 i 1%- fo'/1'/F
P OWNER ADDRESS a?( / Y 44�677/TEL?di'Q Er7 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL g EDUCATIONAL 0 RESIDENTIAL❑
PRINT
CLEARLY NEW:0 RENOVATION:Q REPLACEMENT:❑ PLANS SUBMITTED:YES R NO❑
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 18
FOOD DISPOSER
FLOOR I AREA DRAIN _Rt',ING 7EPA'•TME T
INTERCEPTOR(INTERIOR) °y
_ KITCHEN SINK
LAVATORY /q'd'4-4 56 2-
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
I TOILET 2.
URINAL -
. i WASHING MACHINE CONNECTION yam/ _
WATER HEATER ALL TYPES ) L 1..1 V 9�// S
WATER PIPING
OTHER
•I
I INSURANCE COVERAGE:
{ I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES gtiNO 0
IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY 0 OTHER TYPE OF INDEMNITY BOND❑
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 0 AGENT 0
Z SIGNATURE OF OWNER OR AGENT
LI 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 Plumbinglu Code and Chapter� er 142 of Vera!Laws./96g/ \ , D_
PLUMBER'S NAME Y►I((�� ,)u r'-"" LICENSE# . \�y SIGNATURE
MP❑ JP CA 1 pC v�J ORPORATION 0# PARTNERSHIP❑.# LLC❑�#�Q
COMPANY a;r`t (A r 1 b y�1f ADDRESS 37 `ram n(d'i 'vv e
CITY q/)4/ S r'7 7 STATE /i ` ZIP 0 Z to,6,l TEL'77Y' ' -
CELL
FAX l/7V' ,7 Tit. < ZT
EMAIL F/ ems/ •M r. 0 /C•
(i 1)'1"16 )3,5
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