HomeMy WebLinkAboutBLDP-24-862 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
,___j1=y CITY W•VaVWI ' MA DATE /0-0q 1y PERMIT#W-DP-Z`t- n4_
JOBSITE ADDRESS 5 7 q Wr 11I yQ✓M aV{is R MOWNER'S NAME 7/ni Ch a fa it o
POWNER ADDRESS IQn'C TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL❑ RESIDENTIAL DK
PRINT
CLEARLY NEW:❑ RENOVATION:® REPLACEMENT:❑ PLANS SUBMITTED:YES® 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 GASIOILISAND SYSTEM T -
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 F
SHOWER STALL ` ' .._..-._ �_
SERVICE I MOP SINK
TOILET -
j IT 019 2(O _
URINAL I
. WASHING MACHINE CONNECTION I ,d.Ln vr.r)FVARIIMFMT
WATER HEATER ALL TYPES i
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 0
IF YOU CHECKED YES.PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POUCY® 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
j Massachusetts General Laws,and that my signature on this permit application waives this requirement
•T CHECK ONE ONLY: OWNER❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
Y. 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 compli ce vnth all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ///!�
PLUMBERS NAME LICENSE# aa7.�� SIGNATURE
MP 0 JP a CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME Non( /(o n•Frar-r.ty ADDRESS 3 9 `Ylancmoy I Qs
CITY S`yarnn• STATE rn4 ZIP Gabby TEL SW-68S=S6St
FAX CELL EMAIL ,of((GnutLire "qui" yahe0•co/•-+
3—a
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