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HomeMy WebLinkAboutBLDP-19-004637 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK/ '7 CITY VorW�� MA DATE 2 -� 1 ( PERMIT#/% � 91/9 JOBSITE ADDRESS 44 LA, VQVV1 QV(,V-re.._ OWNER'S NAME Q(�( J kQt C,Z IQD OWNER ADDRESS 14 4 Lz�l Pa v`V V4 lE TEL 'ZSSQ - gf AX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO FIXTURES 7. FLOOR—F BSM 1 2 3 4 5 6 7 8 9 1D 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND 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 k - ROOF DRAIN SHOWER STALL j SERVICE/MOP SINK TOILET L 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 Ei NO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the IT Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT SIGNATURE OF OWNER OR AGENT t I 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. PLUMBER'S NAME LICENSE# 1(GZ6-1 . SIGNATURE MP I - JP❑ CORPORATION❑# PARTNERSHIP❑-# LLC["3 R7S COMPANY NAME ©P.V��i/\ cokk...41I,15-, 1-LC ADDRESS 4. r cez4✓t .))e Q CITY III STATE M.A ZIP 2CO`c�l!/y TEL 6-4-CC ,O FAX CELL EMAIL >tJEU cv\ irru (A-.atic LL-Ce lJ' 1lk .CDw 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