HomeMy WebLinkAboutBLDP-18-004487 MAP: PRI2CEC
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
— 11 i CITY c 0 (f i t k
t , r 1? "IO MA DATE ('2/ice g/
'2IM I PERMIT#/ /1f'lf' 4/Q� 87
JOBSITE ADDRESS 3 ?- It f-rif)/ egA/4 le 6 I OWNER'S NAME ►05 /71 A/f E,4 A/ )/ I
POWNER ADDRESS 3 3 1 I 0 t .�'�' 1 ,v7c•).y9 TEL _SVa q 3£I5 gci( ,FAX I
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL D RESIDENTIAL E
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOD
FIXTURES 1 FLOORS KM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB —_.1 ,J .'LC i ___Ii__
CROSS CONNECTION DEVICE w'NM'1 _ ' .� __ :I __ €(-__,.—i_ I_ ^�
DEDICATED SPECIAL WASTE SYSTEM •_ ; ._,i _ _ i .___ _iI_ 1 =i___1 _
DEDICATED GAS/OIUSAND SYSTEM [ _jI •• 'IM__AI I4,,, : q;__._ _IL„ __d
DEDICATED GREASE SYSTEM —r MIMI`__ ___Ii 1._ .I_ _ _ L� ?(T_ t
DEDICATED GRAY WATER SYSTEM _, II _� •—M j _
DEDICATED WATER RECYCLE SYSTEM _
jill .11_,
i_ _ 9=1Wita
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DRINKING' L_.. 1 IL '11I�r..._� _ ... . _II_ -i
••D • •• 1� _�-��i _:--_.�1i IL ___ sm=f i _ ow
FLOOR •- i =La_:4i _ _ .- _
LAVATORYINTERCEPTOR(INTERIOR) 11 -11— /,.-- 'Hi— . —11_____I iiii ..,,
"!Y III __ L jl, f 1I !- L.____L IJIMI
SERVICE/ •' SINK =1L______L_ _ G.._a IL,.. .11 - —
TOILET
URINAL riii.._
s 31 _II ,I _ 1 _.SLY ii 2 ,ryi
OTHER _L I ._1f. 1 I.�41_____11._ #L I 1___._ I —_IIII.J ____JM
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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 a 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 '
I hereby certify that all of the details and information 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 co pliance •
*alie rrtinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �/ v rr
PLUMBER'S NAME rel orr)c,A.) `" joriym,S Tr I LICENSE# T-3) L(.II SIGNATURE
MP❑ JP DB # CORPORATION❑# . PARTNERSHIIP❑#, LLC # _
COMPANY NAME AiS r,,k l )ho, 1 &CLI Jf I ADDRESS ,SC( 4 WI If DI( L i
CITY L1) 5/. )30,r4 .cz 6le I STATE AG12, ZIP OA 6 ' d TEL . 3 I//,,2 ( 1
FAX 1 CELL S�.u-e 1 EMAIL Ie6er 1-UcT/ ('� 11,E (,,, 1
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
pi if,/ & 0 7( THIS APPLICATION SERVES AS THE PERMIT El 1=1
7//e FEE: $ PERMIT#
PLAN REVIEW NOTES
A
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