HomeMy WebLinkAboutBLDP-24-688 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
_W— CITY tAmi.rvi o c)4, MA DATE g-1 1-2.9 PERMIT# g L O P-Zh- (,
JOBSITE ADDRESS I D 7 v rc)110.)I 0.D/ OWNER'S NAME 5-1-eog f.�..s k_
POWNER ADDRESS S A.rN-P TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL❑ RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:li PLANS SUBMITTED:YES❑ NO 0
FIXTURES 1 FLOOR-, 9SM 1 2 3 4 5 6 7 B' 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE - -
DEDICATED SPECIAL WASTE SYSTEM _ -
DEDICATED GASIOILISAND SYSTEM _
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM _
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN _
FOOD DISPOSER _
FLOOR 1 AREA DRAIN _
INTERCEPTOR(INTERIOR) _
KITCHEN SINK _
LAVATORY
ROOF DRAIN _
SHOWER STALL
SERVICE 1 MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION T _
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 NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY D 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
1 Massachusetts General Laws,and that my signature on this permit application waives this requirement.
'C CHECK ONE ONLY: OWNER 0 AGENT❑
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 lance with all Pertine rovislon of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. A0
PLUMBER'S NAME LICENSE# (0'5-6. SIG RE
MPg JP 0 CORPORATION 0# PARTNERSHIP❑.# LLC 0#
COMPANYNAMERiFp.3Atl4 )IrirvlbrnS ADDRESS 1-1- 1=1.1nr% Qoa1Lr '12i7
CITY ) n A\s STATE /14/'r ZIP 02416.0 TEL 7I/.'27-9207
FAX CELL SoY•3/y-oyod EMAIL I< (' ►iat.j-e 1960 t> d"M'1eu I,C-o°'4
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
4