HomeMy WebLinkAboutBLDP-24-283 \ .i ,, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
a• `/ CITY MA DATE PERMIT# c3LDP-d'Y-.23
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JOBSITEADDRESS (V( NER'S NAME \)V 5V/ J TI P OWNER ADDRESS 5 ,ct c-/t../{ TEL FAX
TYPE OR OCCUPANC COMMERCI EDUCATIONAL 0 RESIDENTIAL Q
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED:YES❑ NO 0
FIXTURES 1 FLOOR-. ISM 1 2 3 4 5 6 7 a 9 10 11 12 13 14
BATHTUB J�
CROSS CONNECTION DEVICE _
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIIJSAND SYSTEM
DEDICATED GREASE SYSTEM _ _
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER ! _ NI
DRINKING FOUNTAIN
FOOD DISPOSER b 0
FLOOR I AREA DRAIN Ti i! rZ 1 _
INTERCEPTOR(INTERIOR) mug _
KITCHEN SINK l L _ r v A
LAVATORY i _ l ,4 •
_
ROOF DRAIN ` 'IJI- I'
SHOWER STALL
SERVICE I MOP SINK I U H
TOILET4.HLWASHING MACHINE CONNECTION
WATER HEATER ALL TYPES `
WATER PIPING //V
OTHER _
_ _
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YE NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement
• CHECK ONE ONLY: OWNER 0 AGENT❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all nest provision of the
Massachusetts State Plu .Ing Code and Chapter 142 of the General
Laws.
PLUMBER'S NAME /j/' ' #0Q-4--a- LICENSE# /5 99 /_ SIGNATURE
MP JP I CORPORATION 0# PARTNERSHIP❑.# LLC 0#
COMPANY NAME f&A V P`/ f u.1 Qa'VCADDRESS .Z 4it,/ it t O // 72 Q
CITY 7� STATE ZIP v 3,r TE ,JW 3/6O ✓ `q 3
/ f
FAX CELL EMAI C�I "I•Ap�) min los
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT ft
PLAN REVIEW NOTES