HomeMy WebLinkAboutBLDP-24-579 O,
\\ s_ MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM PLUMBING WORK
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@ CITY / litrAOvTO MA DATE 6/a7/ay PERMIT#,�L Jy 57i.
JOBSITEADDRESS I i tMC11 T r2rO OWNER'S NAME Tiiyrllc€ Sill/der/
P OWNER ADDRESS 5#144 4.. TEL S-d tS776 W90 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL.'
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:r5 PLANS SUBMITTED:YES 0 NO,Eir
FIXTURES 1 FLOOR—, BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14
BATHTUB I _
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OILISAND SYSTEM '
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER ,
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
ROOF1 LAVATORY (DRAIN r' { �.
i SHOWER STALL I i LP t
SERVICE I MOP SINK 1 11li _ (-.1 i0211_
TOILET 1
URINAL _ BUl ninir nFPARTMFNT
WASHING MACHINE CONNECTION i 1 By._
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 0
IF YOU CHECKED YES,PLEASE INDICATE
�THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POUCY 1a 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
CHECK ONE ONLY: OWNER❑ AGENT❑
SIGNATURE OF OWNER OR AGENT
1 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 co !lance withwith,all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME LICENSE#.Zt/79S. SIGNATURE
MP❑ JP, , CORPORATION 0# PARTNERSHIP❑.# LLC 0#
COMPANY NAME C-mb y S 11!/,/) p ADDRESS 7 6r«N(c v€i 0�A
CITY r ria/T�En d lit r / n L� STATEM I'1 ZIP D a'6 3 a TEL r I -/6 0 S—
ki CELL aofcIg S"t/e05 EMAIL
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