HomeMy WebLinkAboutBLDP-20-002259 Ce
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
—'�V 4 CITY '-'� MA DATE 1 O)ZZ / /9 PERMIT*��i&�go--eo�A,��J
JOBSITE ADDRESS 1 7 /4 1-evAi d) g.D OWNERS NAME Dim- 'O ) �Q/1t, ,✓✓
POWNER ADDRESS 17 LA-1'(e wocJ a TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Q —
PRINT
CLEARLY NEW:D. RENOVATION:❑ REPLACEMENT:[ PLANS SUBMITTED: YES❑ NO La'
FIXTURES 1. FLOOR—+ BSM 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 _
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
_ KITCHEN SINK
I LAVATORY -
ROOF DRAIN
' SHOWER STALL • _
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION •
WATER HEATER ALL TYPES d
WATER PIPING
OTHER
_
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements 0 MGLQ11142 YES Er NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BO C E f V E D
UABIUTY INSURANCE POLICY I� OTHER TYPE OF INDEMNITY 0 BO OCT O ��l�
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance covera r uired by Chapter 142 o thel
'
1` Massachusetts General Laws, and that my signature on this permit application waives this require rill_DINCy DEPARTMENT•
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.-- CHECK ONE ONLY: GENT ❑
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 tathe-best my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provislEirr f the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME VI RS i t,o S;Lv4 LICENSE#3f-5i :0
MP❑ JP d CORPORATIONJ'- ❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME Si Lv4 1 p 6vvt,by UH?i l in .U6 ADDRESS/SE S(..)dbL,py LA!
CITY i4 y.4N AL r S STATE 4 <I ZIP 0360't TEL j
FAX CELL7T9 �3 C4 -le EMAIL yi� ,L„fo, t' I --4 Ai 1 ` /tom
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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1
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