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HomeMy WebLinkAboutBLDP-24-234 MASSACHUS/E�T/TS,UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK a@ CITY I�i-R.iV1/40'J MA DATE 7 & Z'-4 PERMIT#BU-o'1S1- '73r JOBSITE ADDRESS 5 /J PA-7-4 I �f OWNER'S NAME Oe t1 J IS OWNER ADDRESS 573 IMA- TEL 17`i-742-.41rilfA(_ TYPE OR OCCUPANCY TYPE COMMERC EDUCATIONAL❑ RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION' RE LACEMENT:❑ PLANS SUBMITTED:YES❑ N 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 - - DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK .I TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER I _ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL 142 vGp{110 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW R E C V UABILRY INSURANCE POUCY ) OTHER TYPE OF INDEMNITY 0 BOND❑ AR 4 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by[hapter 142 07 of 2 the02 Massachusetts General Laws,and that my signature on this permit application waives this requirement. BUILDING DEPARTMENT ar: CHECK ONE ONLY: OWNER❑ AGENT❑ SIGNATURE OF OWNER OR AGENT LLt I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the bes knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all_Pertine?rt•/• •n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ere _ �tl-�J�/ PLUMBER'S NAME F(b 1 i ;) LICENSE#9q k y. 1/�1� SIGNATURE MP JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME .. ^^ \ Alt ADDRESS i I) ©� "'&�w�� LJJ CITY S f kti t W STATE r` ZIP Da-go TEL,5)3 T t7(/ FAX CELL EMAIL-;,f(e T( P'n 1�N )IV ,,�'� 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