HomeMy WebLinkAboutBLDP-24-848 • - Ld t5( -\irP
MASSACHUSETTS UNIFORM APPLICATION FOR A PERM TO ERFORM PLUMBING WORK
•
��_-= r Cr CITY MA DATE /� (�^ qERMIT
# � ��IAM L u P-Zk c)
JOBSITE ADDRESS l i OWNER' NAME
HvAie--
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION:REPLACEMENT:0/ PLANS SUBMITTED: YES[C44❑
FIXTURES 7 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 r
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER • _
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR 1 AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK T U
LAVATORY _ROOF DRAIN OCT 04 1924 1
_
SHOWER STALL
SERVICE IMOP SINK L.! '� :C-bEli `r/i mENT
TOILET
I URINAL
. 1 WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES _
WATER PIPING
-
OTHER
i ram ) T "r gii-A i - i�.., )--- ,
I
-
i INSURANCE COVERAGE:
I have a current liability insurance policy or its su tial equivalent which meets the requirements of MGL Ch.142. YES NO ❑
if YOU CHECKED YES, PLEASE INDICATE THE PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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
i' Massachusetts General Laws, and that my signature on this permit application waives this requirement.
.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
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 ac urate 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 w II Pertinent provision of the
Massachusetts State P mbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME ,' o( itrid 1V CENSE# I j C..�L�G�6 SIGNATURE
MP LS/ JP t TCORPORATION❑# P-ARRTNERS(HIP!❑.# LLC #
COMPANY NAME 1 "- t ADDRESS 45.-
11 &7 /1oAJ IP
CITYY1/412-1410 07) STATE I"`it ZIP 02-C7 73 TEL 3 39g3
FAX CELL EMAIL)`6'140//nOi icy a U (O'
1 A
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
0