HomeMy WebLinkAboutBLDP-25-27 #24 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
___1 a`� CITY 1f#�RS)44O2 //e_. MA DATE /� if 02� PERMIT# 'i3LD(O-ZS- L7 "rr//
� w JOBSITE ADDRESS f / vi L-� OWNERS NAME �Yu �. �l
POWNER ADDRESS ,r, .474 Lici6a v► Gvl TEL ?4'r9L2 .30QSZ FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:(er PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7. FLOOR-4 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
T
DISHWASHER •
DRINKING FOUNTAIN
FOOD DISPOSER " r
FLOOR 1 AREA DRAIN ` . 1�
INTERCEPTOR(INTERIOR) _ _ T
KITCHEN SINK a 0-8 NZ
LAVATORY
L . T...�. I
ROOF DRAIN BUILDING = -M-E
Y
` SHOWER STALL
SERVICE/MOP SINK ._
TOILET _
I URINAL
. j WASHING MACHINE CONNECTION .
WATER HEATER ALL TYPES
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❑ NO 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POLICY all OTHER TYPE OF INDEMNITY ❑ 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 y signature on this permit application waives this requirement.
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CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF 0 ER OR AGENT
I I hereby certify that all of the detail nd 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/ -rtinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ii, -
PLUMBER'S NAME �CSe5 '��e-C'-`""" � ',
LICENSE#1 SIGNATURE
MP[2 JP❑ CORPORATION 0# PARTNERSHIP 0.# LLC❑#
COMPANY NAME /40s/4Ls(L1I417/44fr ADDRESS, ( 13,c4...E K. 1wK d RJ
CITY tij Q v�c?Z
y V STATE ZIP O 3 TEL
FAX CELL ?. 2 //2 g 2 EMAIL {bt A- jvQ/Y 6-04.aa-,-,,Ccy iz
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