HomeMy WebLinkAboutBLDP-20-002462 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
le--�= CITY YGyiiii.,,(: 7 MA DATE /0 t%- a U/ Y PERMIT#/ 'D`lC'60d r6,
�_, JOBSITE ADDRESS, 3.c 4,,--171-t,^S G,'Y' OWNER'S NAMES 1ht1 :-n TJCGrf-
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OWNER ADDRESS S� •��•� TEL 7 J,/ J ys-//FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL El--
PRINT
CLEARLY NEW:❑. RENOVATION:❑ REPLACEMENT: 12' PLANS SUBMI I I ED: YES❑ NO❑
FIXTURES 1 FLOOR—} BSIv1 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 '
I .
FOOD DISPOSER
FLOOR I AREA DRAIN _
INTERCEPTOR(INTERIOR)
_ KITCHEN SINK
' LAVATORY •
ROOF DRAIN -
SHOWER STALL e ;±
SERVICE/MOP SINK �' `
1 1
TOILET OC T,2 ! ' _
URINAL
WASHING MACHINE CONNECTION
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2r ,),1-,1 f ME
WATER HEATER ALL TYPES I ,v T
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 Etr NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POLICY El' OTHER TYPE OF INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
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CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
I 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 com i be w II Pertt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r/1 - v
PLUMBER'S NAME`11"" f" K/-'"'s'" LICENSE#4-' "a . SIGNATURE
MP Er JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC 0#
COMPANY NAME cCa1 t.�t C.`\ c v,_.L ADDRESS 70 Cv(r n vi I\e D._1 vt-
CITY F., I.re-5 T(; Q it STATE)41 ZIP C'-)4u qy TEL l)l�'-2 6 %"gG8 77
FAX CELL i )F /- 14?-77 EMAIL(r 1U (U Mc P. W")
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
•
•
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