HomeMy WebLinkAboutBLDP-19-006569 CM( .
y MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
-=1-F= CITY ill �,n C J MA DATE 5-2,2 ' / PERMIT#�� P/T
'k„. JOBSITE ADDRESS %2,x GI/c, -Let-- 5 '1-,c'e 1 OWNER'S NAME ' .0
POWNER ADDRESS )c9 TELj s'-771,`�t.`^'V FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 2----
PRINT
CLEARLY NEW: ❑ RENOVATION:E. 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
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM •
T DISHWASHER / _
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN _
INTERCEPTOR(INTERIOR)
KITCHEN SINK , / ,
LAVATORY J •
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET I _
URINAL _
. WASHING MACHINE CONNECTION / _
WATER HEATER ALL TYPES
WATER PIPING
OTHER
i I
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 l
LIABILJTY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND ❑ ; MAY 2 0 20 i
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage regtlir..I.: c if j E �T
Massachusetts General Laws,and that my signature on this permit application waives this requirement. i BY -_ --
T CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
tLl 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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. :/% ,'k;2'T' GNATURE
PLUMBER'S NAME •-. L k A-a'v.r"t LICENSE# !/ 3?�`
MP[`/ JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME m'' 'L, ' Ur%teS O•i n / NTT t-I ADDRESS 61, St14�'"vrl Ll i4'"}-
CITY 0✓X e"*- 1 14' STATE 1704 ZIP 0Z6' 7 S TEL:j`e 776" '? 2 j
FAX C CELL 1 Jv'' 7 7i -Vel L'`? EMAIL Fl-"d l'...H <, hi-,tr,. ail a 1
yr `
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