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HomeMy WebLinkAboutBLDP-24-431 MASSACHUSETTS UNIFORM APPUCATION FOR A,pP_EERMIT TO PERFORM PLUMBING WORK 9 CITY yARTrni) MA DATE ��/�l L a_L\ PERMIT#gL°9-2"l- 911 9 JOBSITE ADDRESS s7 3 A'' l—?-$ OWNERS NAM 1.1...� A y4l P OWNER ADDRESS 5 7 3 /YJ)- r /-©V6-iiC -i TYPE OR OCCUPANCY TYPE COMMERCIAL,N ED CA TONAL" RE•IDENTIAL❑ PRINT APR 2 9 CLEARLY NEW:q-- RENOVATION:' REPLACEMENT: 2024 LANS SUBMITTED:YES 0 N0 .61 FIXTURES 1 FLOOR-, BSM 1 2 3 4 8 ILQI G DE"ART E 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) KITCHEN SINK (;1 LAVATORY _ _ • ROOF DRAIN SHOWER STALL SERVICE MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER IN '4 S, ll /14.1.A) /CC+ q-1 D v�1 .S �1 .♦ •� INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABIUTY INSURANCE POUCY❑ OTHER TYPE OF INDEMNITY ❑ BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. r CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT LtI I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to thebest o m owledge and that all plumbing work and installations performed under the permit issued for this application will be In compli I Pero ent pro I of the Massachusetts State Plumbing Code and Chapter 142 of the General laws. PLUMBER'S NAME l"-U rre.s'T el r (% LICENSE if 7}( (4. SIGNATURE MP jk JP❑ CORPORATION❑# IP rARTTNERSHIP❑..#(� �LLCC COMPANY NAME ADDRESS /� Y/ //''II` �1 �j CITY 6 �1 __ \ STATE TEL�g'c�� /D0 FAX CELL EMAIL n'D ter a7d-rl,6lef UvY , 4'—yY7 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