HomeMy WebLinkAboutBLDP-20-001660 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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- CITY u�►tsa' yCV'NAiv'�h MA DATE 9(aSI/9 PERMIT#,APPeR / 6
JOBSITE ADDRESS /S /via,wt. 411‹.._ OWNER'S NAME ikkcaf 6 cvs-cy
POWNER ADDRESS TEL SO fr- 74 9" a 3(O/ FAX /
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 7
PRINT
CLEARLY NEW: E RENOVATION: ❑ , REPLACEMENT:Kr PLANS SUBMI I I ED: YES❑ NO'f
FIXTURES 7 FLOOR--I BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB _ _
CROSS CONNECTION DEVICE _
DEDICATED SPECIAL WASTE SYSTEM o
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM -
DEDICATED GRAY WATER SYSTEM • -,
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER •
DRINKING FOUNTAIN '7. .
4 cJ _
FOOD DISPOSER
FLOOR I AREA DRAIN /
INTERCEPTOR(INTERIOR) I U
KITCHEN SINK _
LAVATORY -
ROOF DRAIN
SHOWER STALL -
SERVICE/MOP SINK
TOILET
I URINAL
WASHING MACHINE CONNECTION _
WATER HEATER ALL TYPES _
WATER PIPING I
OTHER
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES t7 NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND ❑
i OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
l' Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
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 co (lance - all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,
PLUMBER'S NAME LICENSE# 33 S/7 - SIGNATURE
MP ❑ JP 7 CORPORATION❑# PARTNERSHIP❑.# LLC 0#
COMPANY NAME 6 ri v.ct i S l p 1 1/4,vA s;r,s ADDRESS iD WI Dn a{ .s -1--
CITY VIor tes+r WA STATE � ZIP 41&0 3 �/ TEL
FAX CELL 994' 103- 403d0). EMAIL er .Z Qr;, iS r ri,,..,d,,,S .cowl
zil/
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES A5 THE PERMIT ❑ ❑
FEE: $ PERMIT ft
PLAN REVIEW NOTES
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A