HomeMy WebLinkAboutBLDP-23-8534 y 's MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT/ 2TO PERFORM PLUMBING WORK
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5= :' �/ 24 PERMIT#3t )P�Z3" S63
_-��— CITY /�'R'Ml� �oc�'t MA DATE �
- JOBSITE ADDRESS g p/'ve, sI // /' • OWNERS NAME
P OWNER ADDRESS�� 1a0.0_ i V wIC e/A.TEL 508=/li '065- FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 0
PRINT PLANS SUBMITTED:YES 0 NO 0
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:❑
FIXTURES 1 FLOOR.- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
• BATHTUB t
o1'� CROSS CONNECTION DEVICE
W DEDICATED SPECIAL WASTE SYSTEM
I� DEDICATED GASIOWSAND SYSTEM
DEDICATED GREASE SYSTEM
k DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
V DISHWASHER l
DRINKING FOUNTAIN
j FOOD DISPOSER
Cl FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR) +
KITCHEN SINK
LAVATORY y •
ROOF DRAIN
SHOWER STALL 1
SERVICE I MOP SINK I
p TOILET
i; URINAL
1p��
I WASHING MACHINE CONNECTION
rip WATER HEATER ALL TYPES
WATER PIPING
OTHER
I
� INSURANCE COVERAGE:
;I I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0
IF YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY 0 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 0
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 curate 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 'th al 'ent r 'sierref-tha
Massachusetts State Plumbing Code and Chapter 142 of the General laws.
PLUMBERS NAME LICENSE# 1CZSS' SIGNATURE
MP JP❑ CORPORATION 0# PARTNERSHIP❑.# LLC❑#
COMPANY ?---6, r-- C 14 Yk I ADDRESS 7 IAA h (r r 4-P) � -
W CITY 02--C P -e_ 2STATE N 4'-' ZIP 0(6° 2 TEL
FAX CELL S.--0 Cp J-5) c"?e) EMAIL
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
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