HomeMy WebLinkAboutBLDP-24-977 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
(1. — CITY �' YAt(IV MA DATE ii-as a9 PERMIT# t Zt)('Z� - g,7'�
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�„ n JOBSITE ADDRESS 3 4- COorc L.A-te OfG �'
OWNER'S NAME tvgo
POWNER ADDRESS 3a- "oust 1..-^ne TESc?)itt.(I,4If' FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL EI
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
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' 1 ._.----a-- -‘
LAVATORY \ t�° '` y.3
ROOF DRAIN ` / I/ rr✓`
4 j!
SHOWER STALL % '' A
SERVICE/MOP SINK ` . I BA
TOILET t L
URINAL % 3 +t�'vq p rt+izr+v Ni
j WASHING MACHINE CONNECTION I"�,
WATER HEATER ALL TYPES
WATER PIPING /)
OTHER reryviA4t. r XiaMKLr " f I
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES B NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY 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
1 Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER El AGENT ❑
SIGNATURE OF OWNER OR AGENT
Li 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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
42.0
PLUMBER'S NAME CTet(4OFY se)Fe LICENSE#a6 7 14 . IGNATURE
MP❑ JP® CORPORATION El# PARTNERSHIP❑.# LLC❑# )33/4
COMPANY NAME 6oey `'c-I& ptuhe,ac. ctr,,C ADDRESS qt SPein6ge Lgnc
CITY tot/' YA1illof-c, STATE 01A ZIP 044.73 TELLS°$)>/E- '(13Y
FAX CEL&C ).11(- I43 4 EMAIL SGt ce 9a rra °L youe. (Ori+
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