HomeMy WebLinkAboutBLDP-24-933 54,(/0
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
TZT=a=5� CITY 1ocm0(Yp`4 Po /MA/DATE PVT Agba PE IT# gLOP'2�tit' 13J3 /
JOBSITE ADDRESS.3.5//�/Jbdi./Of)ol//K/ OWNER'S NAME d4:Pl. ( 45 h
POWNER ADDRESS�.CAD//Wepn/ [Yi': TEL7AI"%7 9.14 AX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:0" PLANS SUBMITTED: YES❑ NO Rr-
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/OILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM _
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK _
LAVATORY
ROOF DRAIN _
SHOWER STALL R F (: E I V F D
SERVICE/MOP SINK _' 4
TOILET URINAL
-
URINAL NOV o5
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES 3UILD NG DBPAR7 MENT
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❑ NO[[;�
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY ❑ OTHER TYPE OF INDEMNITY❑ BOND❑
' OWNER'S INSURANCE WAIVER:I am aware th t the licensee does not have the insurance coverage required by Chapter 142 of the
t= Mass usetts General Laws,a that si ture on this permit application waives this requirement. �
2 444��� CHECK ONE ONLY: OWNER�✓J AGENT❑
GNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application a e and accurate to the st of my owl dge
and that all plumbing work and installations performed under the permit issued for this application will be in mpliance 'th all Pe proviai of
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME �p,�f�e l Clvs /Q/17 LICENSE# f/659 SIGNATURE
MP[y� JP❑ CORPORATION❑# PARTNERSHIP OH LLC❑# /
COMPANY NAME_ �a// /> 7 4 c 9�/`s j ADDRESS 75 K/10//in 6/ df..
CITY //v1QU.Q �PO/ STATE i. ZIP /99/( 75 TEL 7
FAX CELL 746/'-//;26'-93'.3 EMAIL QC's✓I('IIiS `n7 9 m
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
I