HomeMy WebLinkAboutBLDP-24-964- s� MASSACHUSETTSS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
-a. CITY q/'h+Pew t// MA DATE / °7_ PERMIT#NAV—7""cl(rn
JOBSITEADDRESS /57/7 rhur,4e, f r.c7 OWNER'S NAME I3/'g Ze ('
P OWNER ADDRESS/-5-7/ rY �ir�.571,cG7` TEL `l Z 7? _FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIALLY
PRINT
CLEARLY NEW:❑ RENOVATION:V REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO 0
FIXTURES 7 FLOOR—, BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14
BATHTUB I _
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM _N I C E V El.'
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM NOV2120A1
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER _
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY / T _
ROOF DRAIN
SHOWER STALL _ I _ _ _
SERVICE I MOP SINK
TOILET I _URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
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 21/7
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
J Massachu��Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER[/1/AGENT❑
SIGNATURE OF 0 ER OR AGENT
`I I hereby certify that all of the details and information I have submitted or entered regarding this application are true and-. •a e to e•-t of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co r•' .±�'th all P inent• ;'•-- •-
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ma //610•••
PLUMBERS NAME LICENSE#"icy O. SIG ATURE
MP❑ JP V CORPORATION❑# PARTNERSHIP Q.# LLC 0#
COMPANY NAME ,/I!, ��' ADDRESS'4" , e4/11-f ' ,% •
CITY STATE IW. ZIP d, 53 a TEL 7/1'^S7/—/3/4
FAX CELL EMAIL 72rroom09@ yQi7t✓�•(1,rr7
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT It
PLAN REVIEW NOTES