HomeMy WebLinkAboutBLDP-19-005664 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
CITY Ye--v- t "1 MA DATE Vi y/5 PERMIT# /91'0P P' ✓10
JOBSITE ADDRESS / /tfI ro Pr' OWNERS NAME 0-A-de;i
OWNER ADDRESS / I�I� (�,1/(jw TEL TEL re/ , ti 7 /S 3 7 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[1�
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMI I I ED: 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 1
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
URINAL
WASHING MACHINE CONNECTION
I 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. S_• ° No..
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
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^/ MI!R 1 2Q19
LIABILITY INSURANCE POLICY dd' OTHER TYPE OF INDEMNITY 0 BOND 0 a `
L__.
BUILD Li NI
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage requir day 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 I hereby certify that all of the details and information I have submitted or entered regarding this applica' e and accurate o the best of y k Wedge
and that all plumbing work and installations performed under the permit issued for this application will be in mplia with ert�erPr of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C/
PLUMBER'S NAME 07-10,.) (/..✓/ LICENSE# /3 49o?. � SIGNATURE
MP 0( JP❑ // CORPORATION!!f#2 C y(, c PARTNERSHIP❑.# 1 / LLC❑#
COMPANY NAMEPr4., CLr/L /AA., b, vQ ADDRESS 7 _irk,/ ere.-.cc
CITY 4104 .13r. STATE Wi.z. ZIP 4,.7.7'y TEL 5' 8- 3 aCr '// 7/
FAX CELL.5b 3a..G 4/1 7I EMAIL c 7 s��. O
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY IaINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES