HomeMy WebLinkAboutBLDP-24-592 MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM PLUMBING WORK
='ate CITY i ^ J a f pel ou I-VI MA DATE T/2-A/) Z1 PERMIT#aDP-Jr- 59-
JOBSITE ADDRESS z yo/z y? 50.Sao si -- OWNERS NAMFOCJ/0 S /7�QI'/n
POWNER ADDRESS TEL FAX \/
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL X.
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:L$, PLANS SUBMITTED:YES NO❑
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/OIL/SAND SYSTEM _
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM _ _
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR) -
KITCHEN SINK ' _
LAVATORY 2- 2
ROOF DRAIN R C F. P v E ,
SHOWER STALL 1j _
SERVICE I MOP SINK �n
TOILET 2._ G, - W 70 it -
URINAL _
WASHING MACHINE CONNECTION fi _ BUILrlING D_PARTMFN-
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. YES4 NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY g 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❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
LI I hereby certify that all of the details and information I have submitted or entered regarding this application am 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. ( 1 ht.I r?
PLUMBER'S NAME M\cL weLk J r`'4^-' LICENSE#�� `SIIGNATURE
MP 0 JP U CORPORATION❑# pia p PARTNERSHIP Q# LLC 0#
COMPAN AME 1'C(-IL P V—u- ADDRESS gj 7 �rlM L-I1,/i i i-t r' -v ('-(
CITY Ct-f i t 5 STATE VIA` ZIP 07(0 6 i TEL 77f V/o 7/z-
FAX CELL EMAIL 5-1 Mt-ef'•(y1 c.J r1410(Di M,4i t..'041
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT (l I I
FEE: $ PERMIT #
PLAN REVIEW NOTES