HomeMy WebLinkAboutBLDP-20-000944 MASSACHUSETTSp ) UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
— / CITY A �/ 'W V t 1�� MA DATE 6 PERMIT#!U P 0- 7yy
JOBSITE ADDRESfril \2fA, OWNER'S NAME 1)11 �tS���O/ �� I VI
POWNER ADDRESS y7 , ' i✓i - / 9T X TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL E EDUCATIONAL ❑ RESIDENTIAL L7
PRINT ,/
CLEARLY NEW:LS RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMI I I ED: YES❑ NO❑
FIXTURES 7 FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB t'
CROSS CONNECTION DEVICE i
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
aDISHWASHER j
DRINKING FOUNTAIN
, FOOD DISPOSER
-J FLOOR/AREA DRAIN -! y'i/INTERCEPTOR(INTERIOR) r RE C E 1111E D
KITCHEN SINK / - _
LAVATORY -_ fr
ROOF DRAIN AUGA 2�;
SHOWER STALL I 4
SERVICE/MOP SINK -� BU!!C!Nq. -
DEPC RIME NT
__..) TOW ( 6Z "'--,_ r_-_.__rv—_ —
URINAL
i WASHING MACHINE CONNECTION / •
WATER HEATER ALL TYPES
WATER PIPING I
• OTHER i!f k--) J t v1- I
- 1
g II
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES El/NO ❑
9___6". IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
c. LIABILITY INSURANCE POLICY [ 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
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 a urate to t best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complianc th all P in nt prpvi ' n of the
Massachusetts State Plumbing Code anted Chapter 142 of the General Laws. c. �-
PLUMBER'S NAME --CL C 6 ``� l tk LICENSE# Z.-C)541 SIGNATURE
MP ❑ JP(a' CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME c, (o/V\ ") '1co ADDRESS To box_ \t
CITY J ��� 11-� STATE V CIA ZIP �`-3`��> TEL
FAX CELLSOZ -2-(:53 iVi7 EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
, / Yes No
YJ�� �F j /✓ / r) THIS APPLICATION SERVES AS THE PERMIT
6�.(/ /ie-
1 ( !r FEE: $ PERMIT#
PLAN REVIEW NOTES
/CVO )� T M /.5-
74- 40 it-97-
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