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Home My WebLink AboutBLDP-20-002752 0.3L Ft- t/op, t O �75 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING ORK CITY 1A't-"1 w mil. Ai"' y 24; S rt� 1°I_ ' MA DATE PERMIT#!✓� e)�,y JOBSITEADDRESS 2-2.3 2TE L k OWNERS NAME J/// YlA .'.%Z i, ✓ OWNER ADDRESS TEL-CZ'rG JG Z $9G -FAX TYPE OR OCCUPANCY TYPE COMMERCIAL a- EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW:❑, RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑ FIXTURES 1 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) a KITCHEN SINK LAVATORY • - _ ROOF DRAIN SHOWER STALL SERVICE/MOP SINK - TOILET URINAL WASHING MACHINE CONNECTION F WATER HEATER ALL TYPES at f' I - WATER PIPING 1 OTHER T M LIVT/ "l/ I L.� _ INSURANCE COVERAGE: Er-NO I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES LI/NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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❑ AGENT❑ SIGNATURE OF OWNER OR AGENT 1-1-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 my knowledge and that all plumbing work and installations performed under the permit Issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME W/c.t ,,t es-7 m LICENSE# / Z o-Z/ SIGNATURE MP Er JP El CORPORATION❑# PARTNERSHIP DI LLC❑# COMPANY NAME <It/n J t,,,et 6 ,,.7 ADDRESS Kr 4-'./ STze-a-T CITY - '/1,JO by,CI, STATE /174 ZIP UZd'L? TEL Sde. 77 L /uu j FAX CELL 77Y YF'7 f/70 EMAIL 4i//s 33u t7 4 L eht 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 1 • j t � ' I ` .3(: -.47,1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK =11=�` CITY `jA 2v.-r dV i'L MA DATE uN y 2-of 5 PERMIT# �Yr�� 2 Z 3 /L'Tc� L �F - JOBSITE ADDRESS OWNERS NAME D(i) A POWNER ADDRESS TEL Pig- )4 2 5 96 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0' EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW:D. RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑ FIXTURES 1 FLOOR-+ BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE _ , DEDICATED SPECIAL WASTE SYSTEM 0 DEDICATED GAS/OIL/SAND SYSTEM 1 1 �_ /s DEDICATED GREASE SYSTEM /o t I DEDICATED GRAY WATER SYSTEM , a ' " a • DEDICATED WATER RECYCLE SYSTEM C� " DISHWASHER _ DRINKING FOUNTAIN h1Ea FOOD DISPOSER �h FLOOR/AREA DRAIN - _ INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALLi 1 Vic /�t � v! SERVICE J MOP SINK TOILET ____ URINAL �. `. �� - WASHING MACHINE CONNECTION I WATER HEATER ALL TYPES I N lO V (1 4Art& t, 1 WATER PIPING i 0 zi , OTHER • "it i7 . ur_1-7-1t-Z, ,A, irc4 f ,....._ , INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 2'1;0 ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POLICY 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. s CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT 1-:_l 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 all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME G✓ic,t ,.,esi /eG�71 T LICENSE# / Z Q 2/ SIGNATURE MP Lr JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME �'t /d „ 0,,,-.4. 6 , ADDRESS Kr- +,-" u' S I •T- CITY -Yn.u,*) Lvi t4 STATE h74 — ZIP U2.6'Z3 TEL S, 72 6 /U✓ j FAX CELL '77 y ye 7 , /7U EMAIL rli/i's o,7- 3 3c' C 74-7<1/, C.,._ 471E