HomeMy WebLinkAboutBLDP-23-11899 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
.,---`_- CITY ✓ ( /i n"JGVFZ? MA DATE (i /Z I /a--J PERn�t IT# /2J- rly,�l i
JOBSITE ADDRESS g ( r(/1 SC'/- L.r r� OWNER'S NAME✓"I/L (;(�'(r q 71
POWNER ADDRESS ZO /- r- /.01 U�AO �'y '7'TEL CJI7/. Z.5 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL II
PRINT
CLEARLY NEW:` , RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES 1°tJ NO 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 GASIOILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM L,
DISHWASHER / --
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY 2 Z
ROOF DRAIN
SHOWER STALL /
SERVICE I MOP SINK
TOILET 7 z
URINAL _ i-��'''�.., ti
WASHING MACHINE CONNECTION / L . C., 7; F a
WATER HEATER ALL TYPES /
WATER PIPING
OTHER " ' 2 i r•
.-rfu,LJTrvi,ut- AK POCK"
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESC NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POUCY 1. OTHER TYPE OF INDEMNITY❑ BOND❑
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❑
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 all Pertinent provision of the
Massachusetts State Piumbi Code and Chapter 142 oft General Laws. •\ r
PLUMBER'S NAME TA 1(qi e L AcR r I LICENSE#/?611. \J�J— SIGNATURE
MP❑ JP[11 CORPQRATTIOON 0# PARTNERSHIP❑.# / LLC❑#
COMPANY E M r� C 1 OC_D ri) -1 6 4- ADDRESS 7 -r 4-1-4 Li(7) L'/I7 ise4 f,.Q
CITY I G, n!\t 5 STATE IM11- ZIP .I; Z L,O/ TEL , f/4 c-,
FAX 111 CELL 77y7/05l/ZZ EMAIL 5�//1 I/ iiYA ericQQ4yi/ i1t• (62.vv,
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