HomeMy WebLinkAboutBLDP-24-966 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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_`_�'—- CITY\� - A(JL MPU 1-t MA DATE ` t —1j3—� PERMIT#BL D P-2H "1"
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JOBSITE ADDRESS OWNERS NAME Cn r t t r(A-4J
POWNER ADDRESS r, TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL p--------
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO 0
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 _
DISHWASHER 1------
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY 2- • 'I C . r- d e D
ROOF DRAIN i __ ___
SHOWER STALL l-
SERVICE I MOP SINK I , I I I '
TOILET 2
URINAL _ I
_ e
WASHING MACHINE CONNECTION By _ NM
—
WATER HEATER ALL TYPES
WATER PIPING ✓ r/
OTHER
.
i INSURANCE COVERAGE:
I 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
UABILITY INSURANCE POUCY [� OTHER TYPE OF INDEMNITY 0 BOND 0
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 0 AGENT❑
Z. SIGNATURE OF OWNER OR AGENT
Lii 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 v)II be in comp anc +ith all Pertinent pr vision of the
Massachusetts State PlumbingCode and Chapter 142 of the General Laws. /I(()_
PLUMBERS� RS NAME - ?) c c ,D 2,(245)6E LICENSE# ( t 3 4 SIGMA E
MP L JP 0 CORPORATION 0# PARTNERSHIP Lj# LLC❑# 0` J"t-
COMPANY NAME C Lc)`.2'21136c I'Ai21 t u V ADDRESS 1D U O
CITY LJ` 1� L"i t c4-1 X'�I°STATE MA- ZIP C.__�� 1 TEL
FAX 5CE�CL —046S EMAIL��RCC PTT
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laU,vI) Ck 777777 @ . 6 A/`/\--IL, uM
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