HomeMy WebLinkAboutBLDP-24-677 \-) 6°
\7' ;\
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
��= CITY y/f
/� hZOVTrt j7 2 'i /PERMIT B4--0P-Z'1- (7.7
E === MA DATE #
JOBSITE ADDRESS 3 v M 4,C I 0 /ci OWNER'S NAME A� v'�-"
OWNER ADDRESS TEL .--V Y. t-1 A
p � r
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: EPLACEMENT:❑ 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
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER J
DRINKING FOUNTAIN _ _
FOOD DISPOSER
FLOOR 1 AREA DRAIN
KITCHEN IINTERCEPTNKR(INTERIOR) i_ E~ �'
LAVATORY E ---- .ti,k !
ROOF DRAIN
SHOWER STALL + ',' NUG 07 2024 'F
SERVICE/MOP SINK 3
TOILET / / so '1,_
-�1U`1 ,yNG ,c' �+Etr rnCPaT q
i
____"""'.'"�---�- -_._
URINAL
uy—
WASHING MACHINE CONNECTION /
WATER HEATER ALL TYPES
WATER PIPING 1
OT ER
4A CC fi
U 'X I/45
y
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YE 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 ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachuse neral Laws,and that my signature this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT��.---.--
SIGNATURE OF OWNER AGENT
I hereby certify that all of the details and inf rmation 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 ' a eminent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. --e,,
PLUMBER'S�NAME Sc cl l OW II
LICENSE# /60 22 SIGNATURE '---:-.4.---c
MP(,d' iP❑ / CORPORATION Vigor? PARTNERSHIP❑# tic❑#
COMPANY NAME A/ CA 1pv_4; -ilk'C ADDRESS .�5 cd./, ,
CITY_ �OX TO iV/ STATE /4 ZIP y�
�'/.�7 k 6 TEL J� --?''�' . if(,( i- "36 Ir
FAX CELL_ EMAIL /cCv/4( 0 Oit/ei4',76",,,1! ‘,60Jf