HomeMy WebLinkAboutBLDP-24-646 JZ- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT 0 PERFORM PLUMBING WORK
f CITY MA DATE 2_ 2 "PERMIT# ige I ) L'
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JOBSITE ADDRESS l OWNER ADDRESS (CAP i S Leyj� OWNER'S NAME .I (��{�1Ile� 4 Lj 4 n !1
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TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL{
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CLEARLY NEW:E RENOVATION:( /'REPLACEMENT:110 PLANS SUBMITTED: YES[f NO❑
FIXTURES 1. FLOOR-1 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB I
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
LAVATORY I
ROOF DRAIN _ _
SHOWER STALL '
SERVICE/MOP SINK
TOILET L l ,
URINAL
WASHING MACHINE CONNECTION J
WATER HEATER ALL TYPES
WATER PIPING
OTHER p®r-Pat Z
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[y' NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [ OTHER TYPE OF INDEMNITY ❑ BOND ❑
i OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
t Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT E
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 compliance with all Pertinent provision of the
Massachusetts State Plumbin Code and Chapterf � 142 of the eneral Laws. i &
PLUMBER'S NAME, l O"Ari(,e L " `W6 rt LICI E# �/ 2 SIGNATURE
MP❑ JP 1, CORPORATION❑# PARTNERSHIP❑.# LLC❑# /~ col)
COMPANY N'ME ' IOU HA— ADDRESS f<-rc 4L'` Li.?
CITYN-14CI A AL S STATE MA ZIP 02b 0 / TEL -7 1 Y 70 7 u
FAX CELL EMAIL '7% i if?Z , YviC 13J?I 1 L j
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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