HomeMy WebLinkAboutBLDP-24-285 4'1,0.00
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
qI��'��G
CITY ��^ r�a �yMA DATE 1 / �� L1 �P}ERMIT#WD".",6
JOBSITE ADDRESS ,l 7 1 I-,D OWNERS NAME /4 "�C"4"
P OWNER ADDRESS ,j 7 3 m TEO)y of I Z96 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT PLANS SUBMITTED: YES 0
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 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 f _
LAVATORY •
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK
TOILET
URINAL _ _'SF1: EIVr1
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING MAK_1 9 ZUA
OTHE ,, t)J r)I BOIL DING DEPARTMF_N'L_
—
i INSURANCE COVERAGE:
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 POUGY. — 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
zLi
CHECK ONE ONLY: OWNER❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
L: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 Vest knowledge
and that all plumbing work and Installations performed under the permit issued for this application will be in comp)nce with all Pertinent pr io of the
Massachusetts State Plumbing Code and Chapter 142 of the General laws. ,
PLUMBER'S NAME �v("-e,T (1�r,�1( LICENSE# b�il SIGNATURE
M JP❑ CORPORATION 0# PARTNERSHIP❑# C❑#
COMPANY NAME
/� ADDRESS/C i CU Gt 1/11
CITY PAOLU cCe,A STATE, 211>� TEL p`
FAX CELL SV V(7 EMAIL- O(YPP IltP_,/a VJA ,Q o
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