HomeMy WebLinkAboutBLDP-19-005663 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
i CITY yA✓f.1O•/ MA DATE 3/Y/9 PERMIT#bi--/A1?-0066.1
JOBSITE ADDRESS 2 5-9 0/ f Th- /yo 6/SC Pe OWNERS NAME >0z 4Le
OWNER ADDRESS c ?5 /vvse Rtil TEL ,5--OF 3F1' 09O4FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES E NO IC
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
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
. WASHING MACHINE CONNECTION •
i WATER HEATER ALL TYPES
WATER PIPING
OTHER
i
INSURANCE COVERAGE: - - ----
i I have a current liability insurance policy or its substantial equivalent which meets the requirements of M Lh. 2CYeS
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BEL W .31/6-(4)
LIABILITY INSURANCE POUCY L'� OTHER TYPE OF INDEMNITY ❑ BOND ❑ MAR 14 2019
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage req it 4' f�1
t H1/t6f1El4' NT
By
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this applicati e and accur to to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be In co pli e w all a ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME Of 1u r k LICENSE# /3c Yam_ SIGNA RE
MP JP❑ CORPORATIONd.t.,24.4/4 L- PARTNERSHIP❑.# LLC❑#
COMPANY NAME /n._, r A/s^^'p/"'v(� ADDRESS 7,44 cy v I ew tr C f
CITY / 4 V- Oetetlft h s- STATE Mc. ZIP Q..r?9 TEL S'd 3 2. yi7/
FAX CELL .0 r 346. h/17/ EMAIL /1115 /a (9-t�- !' ( 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