No preview available
HomeMy WebLinkAboutBLDP-24-833 l MASSACHUSSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �i CITY NI w r,•\ —MA DATE l�,- 14\ PERMIT __11#\\�-D i-2r._933 JOBSITE ADDRESS I\ o Z'r DB OWNERS NAME 13 'Ah Mna. \ct`\ }wrK`` `\ P OWNER ADDRESS I I7o R1S 3$ TEL 503-1 Sim FAX TYPE OR OCCUPANCY TYPE COMMERCIAL r$ EDUCATIONAL 0 RESIDENTIAL 0 PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:151 PLANS SUBMITTED:YES 0 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 GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM _ , DEDICATED GRAY WATER SYSTEM _ _ DEDICATED WATER RECYCLE SYSTEM _ DISHWASHER ' DRINKING FOUNTAIN _ _ FOOD DISPOSER FLOOR/AREA DRAIN _ _ INTERCEPTOR(INTERIOR) ///—E D KITCHEN SINK R LAVATORY I �>$ ��` ROOF DRAINSEP 27 i i SHOWER STALL _ C SERVICE I MOP SINK - TOILET I BU LDINC DEP>j It 'NT URINAL - - By WASHING MACHINE CONNECTION _ _ WATER HEATER ALL TYPES _ - WATER PIPING OTHER _ - — INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES tt NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY It 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 requiremenL T CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT L`.I I hereby certify that all of the details and information I have submitted or entered regarding this application are tru accurate to Ih st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co it I P rovision of the Massachusetts State Plumbing Code and Chapter`eu 142 of the General Laws. 1-� PLUMBERS NAME( r K\\ y ' LICENSE# )3r). SIGNATURE MP 141 JP 0 CORPORATION❑# PARTNERSHIP❑.# LLC 0# COMPANY NAME C IV'.i 3b., PJt\ p�� ADDRESS7�0 M � �1 CITY 1 v ems(' - ` (- STATE{"y't ZIP (6W' TEL FAX CELSOY �c',5) EMAIL GCt�\VW ��e �6�ou.Cates 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 I