HomeMy WebLinkAboutBLDP-24-976 AO° MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
__40-. CITY ?( r.A 1),,1 MA DATE 1j?Zc 1 2-( PERMIT#BLA P-2i-41-7f-
JOBSITE ADDRESS 1 (e, A)_ 0'44c,.!h (.L OWNER'S NAME Me-tUxL-.a„q
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 2----
PRINT /
CLEARLY NEW:( ' RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO 0
FIXTURES 1. FLOOR-. BSM 1 2 3 4 5 6 7 6 9 10 11 12 13 14
BATHTUB _ _
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOIUSAND 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 1 _ � 1 V.,
ROOF DRAIN
SHOWER STALL ( �{;;'J
SERVICE I MOP SINK v!J
TOILET tHT
URINAL _
WASHING MACHINE CONNECTION ( .-e0G 0 ./
WATER HEATER ALL TYPES Ot�
WATER PIPING ev
OTHER _
1_
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES lEr NO 0
IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY L� 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
1 Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE ONLY: OWNER❑ AGENT❑
SIGNATURE OF OWNER OR AGENT
lU 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 as plumbing work and installations performed under the permit issued for this application will be i cort mpi nce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. .-
PLUMBER'S NAME v v cA, 3-o'•"t..Ct LICENSE# 1SG2(C SIGG LIRE
MP[P JP 0 CORPORATION 0# PARTNERSHIP❑.# LLC 0# /
COMPANY NAME LS.b*'v'�'l Pa-kA ADDRESS 106 -L-) f e� w
CITY )--korct. I/‹e_ STATE f ',c ZIP O2w`-4 A TEL SD --S 1-/11 ^`-('is—let
FAX CELL EMAIL R-nrv't 0.curti:..„.3 4, C9 ., I
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