HomeMy WebLinkAboutBLDP-17-001794 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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� 1 MA DATE 5 l I PERMIT# �l7�C�OJ
JOBSITE ADDRESS 2cb Ri; LOG,t wo,y OWNER'S NAME �LU� �(1Co + Pq '`�-
OWNER ADDRESS 2j i-/'y,tl, ,tc U.JLk/ / TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ /EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
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
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER _ _
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN _ _
INTERCEPTOR(INTERIOR) _
KITCHEN SINK
LAVATORY-
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET 7C
URINAL
WASHING MACHINE CONNECTION -
WATER HEATER ALL TYPES _
WATER PIPING ><‘
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES, 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
Z I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurst th est of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in com lian i Pe sne pr ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME LICENSE#320 7 . SIGNATURE
MP ❑ JP, CORPORATION ❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME J I at..k...12/ Pit:M -A-70 ADDRESS 76 54A ef "
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CITY �c 4 yU r rYlatiiik STATE in 4 ZIP 626 l TEL Q;'_22.t
FAX CELL 22 J -s 7 EMAIL -J t(4,)\-,v.p y pi kikr)b;x3 \ H?e� l 4, -r1
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
f(e// ' D/`1 Ue/71 /G7/7//fv Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $_ PERMIT#
PLAN REVIEW NOTES