HomeMy WebLinkAboutBLDP-24-856 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY `1A G� MA DATE 10 "mil— Z9 PERMIT#, �� Z�` TSB
JOBSITE ADDRESS .10 IL tl,'Ne OWNER'S NAME �w�IV UQXT�C'
OWNER ADDRESS Some_ TEL Yd 37y '6 ' F4X
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL L�J
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES-. 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 I AREA DRAIN _
INTERCEPTOR(INTERIOR) '
KITCHEN SINK _
LAVATORY / • _
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK �( /
TOILET
URINAL i
i
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
i OTHER
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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 11NO L'7
i
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BO) BELOW
LIABILITY INSURANCE POLICY ❑ OTHER TYPE OF INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverag required by Ch iter 142 of the
Massachuset s General La , and that my signature on this permit application waives this requirerient.
T -)--1 CHECK ONE ONLY: OWNERElAGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application ara true and accura•a :o the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in c)mpl�with all P art nt pr ision of the .,
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# � I�� S,C NATURE
MP JP[ CORPORATION❑# PARTNERSHIP❑# _LC❑#
COMPANY NAME �'i L:3"ti �k`tools D ADDRESS 2
CITY LI lott MO CA, P31T STATE M A, ZIP Da.4, TEL
FAX CELL SOg—3C 7—(oy"3 EMAIL eAykYwd l", fiyr.242 . Cori
-20
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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