HomeMy WebLinkAboutBLDP-23-10094 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
Nip) CITY x�l J �� - MA DATE / 7 PERMIT# Po_Yetiffery/) `� ,3 �G'c.`.f)JOBSITE ADDRESS?U°S)Cie#7.4h�nd 'IF OWNER'S NAME (�(�7/a _lOWNER ADDRESS ccoe TEL6/ r /FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL El RESIDENTIAL%
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 j R F f T I V F'D
DEDICATED GAS/OIL/SAND SYSTEM ` f
DEDICATED GREASE SYSTEM I 2024 _
DEDICATED GRAY WATER SYSTEM I_ _
DEDICATED WATER RECYCLE SYSTEM M �i to pi Ni: Dr r.{,yRT N(FNS
DISHWASHER • w
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL /
j SERVICE/MOP SINK
' TOILET
URINAL
j WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
In oGt)r (,1 cr/ve l
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 OTHER TYPE OF INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
ft 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 hereby certify that all of the details and information I have submitted or entered regarding this application are true d 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 p ce w I Pe e, provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# SIG URE
MP 1 JP❑ j�CORPORATION❑# PARTNERSHIP 0.# ,,LL'C❑l##
COMPANY NAME Phife--6)`�;V
ADDRESS L.5 /� �/1 /q0 / // C;CD
CITY /0(Y 1'C2 j lie STATE n') 9 ZIP O VC TELCj/FAX CEL /0- �U t?-Ll 9? EMAIL rC�/ 7?edI,y14yC/h00.rein
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