HomeMy WebLinkAboutBLDP-24-370 (3) MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
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=_11=a� CITY y "egoi2-._ I MA DATE 1C� '2 y PERRMIT#j�/1.1�-aci-37v
JOBSITE ADDRESS a�''I C) n C l 2). OWNER'S NAME v-U2pi+441 AMy
OWNER ADDRESS any E.JcX7� lJ TEL,SO -Mk, FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAt4
PRINT
CLEARLY NEW:❑ RENOVATION: , REPLACEMENT:0 PLANS SUBMITTED:YES❑ NO❑
FIXTURES 7 FLOOR-4 BSM 1 2 3 4 5 6 7 B 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 X. •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY •
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK _ _
TOILET
URINAL
, WASHING MACHINE CONNECTION _
WATER HEATER ALL TYPES _
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO ek
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POLICY 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
Mao huusett�ttts/s General Law nd that my signature on this permit application waives this requirement.
•
're / CHECK ONE ONLY: OWNER 0 AGEN40
SIGNATURE OF OWNER OR AGENT
L:l I hereby certify that all of the details and information I have submitted or entered regarding this application am 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 corn lia w all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME _) k.4 �u//h LICENSE# oZ SIGNATURE
MP❑ JFEL CORPORATION 0# PAR RSHIP Q# LLC 0#
COMPANY NAME I t n V p/(,2 rh 6 1 ti ADDRESS/c c IZCyJ+.t✓ale
CITY �✓ yfiftino U 1�. 11• STATESTA /7/- ZIP oa 6-7-3 TEL sag-cfoZ.*-1191
FAX CELL SOSr' 7,2L- I13 J EMAIL' riLJM j 6 C ar'c.fir: %NI e T
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
£i2 01y C FS Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT it
PLAN REVIEW NOTES