HomeMy WebLinkAboutBLDP-23-11672 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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PERMIT# OGie 2 -//(7
JOBSITE ADDRESS OWNER'S NAME 1Z u,bi n
P OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL[3
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO❑
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 I AREA DRAIN _
INTERCEPTOR(INTERIOR) _
KITCHEN SINK
LAVATORY
ROOF DRAIN _ _
SHOWER STALL
SERVICE I MOP SINK _
TOILET
URINAL _
WASHING MACHINE CONNECTION ,
WATER HEATER ALL TYPES _ _ _ ,
WATER PIPING _ _
OTHER
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IA)' lY1 11 oo l LL'1 INSURANCE COVERAGE: j R
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL h. 42. YES IL NO p
IF YOU CHECKED YES,PLEASE INDICATE THE E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 4 up, 2 9 20t 3
UABWTY INSURANCE POUCY U� OTHER TYPE OF INDEMNITY ElBOND❑ ;j itu-(rYv-C)5PAFz7MEN
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required "' er ,2 of the
1 Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT❑
Z SIGNATURE OF OWNER OR AGENT
�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 P_ nent provision of the
Massachusetts State PlumbingCode and Chapter 142 of the General Laws. /,r,c" ( I
PLUMBER'S NAME Teky e, l- i\ er ( LICENSE# I f2I 1. SIGNATURE
MP JP 0 CORPORATION LJ# PARTNERSHIP # LLC 0#
COMPANY NAME J fr-v't?el. P(I,U YYt b i ADDRESS 'I/ 'I IA) I1 c I Pa? (..1-1-kyl R cf.
CITY [ IA`r VA au STATE M cZ ZIP ji /‘ L I TEL
FAX CELL cO k' a 3 T 3.-5-5;''I EMAIL J 1 ( L ,11O P,,r 5' 3 L. �` IV/G'1, -
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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