HomeMy WebLinkAboutBLDP-25-373 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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.='TF=_a` CITY Q(-I/Vl O'�l� ` MA DATE Li'/6 -Z'� P<ER_MIT#&DP-2�r-- 3`�3
JOBSITE ADDRESS ?C`) GQ�D OWNERS NAME Sinflrt 'Pri m ro, 2
P OWNER ADDRESS TEL FAX__
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:m/ PLANS SUBMITTED:YES❑ NO 0
FIXTURES 7 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 y _ V E D-
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) - -
KITCHEN SINK — _ APR j 6-
LAVATORY •
ROOF SHOWER STALL N o•ill rnil�r1Fa- 'MENr
SERVICE/MOP SINK
TOILET _
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES /
WATER PIPING
OTHER
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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 THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY 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
i Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
L1.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 m knowled
and that all plumbing work and installations performed under the permit issued for this application will be in so Hance withall Pertinen ro•I the
Massachusetts State Plumbing Code and Cha ter 142 of the General Laws.
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PLUMBER'S NAM E'TrlGA Cla LICENSE# 13i6 1 SIGNATURE
MP,VJP 0 }-u CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NA `(3 I(/0-n614 - i#;, �r/� ADDRESS CPS-N Z278
J1 CITY O Cj j STATEP1/4A- ZIP OZ�[,. TEL
FAX CELL S �G/-7y3 <pa EMAIL YI Vti' 1'3 4;t9/7-2a.rt Coin
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