HomeMy WebLinkAboutBLDP-24-100 MASSACHUSETTSp UNIFORM� AP'LICATION FORI PEER/IMIT TO PERFORM PLUMBING WORK
CITY L} 1Y�1 QN t �M/A DDAJT'E1 ! I7 / 2 f PERMIT#�C DP-2H- t 00
JOBSITE ADDRESS ( 2— COVE y la/ a- OWNER'S NAME
POWNER ADDRESS Sit;- TEL FAX__—.
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT:0 PLANS SUBMITTED:YES❑ NO❑
FIXTURES 1 FLOOR-, BSM 1 2 3 4 5 6 7 6 9 10 11 12 13 14-4
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 I AREA DRAIN
INTERCEPTOR(INTERIOR p�
KITCHEN SINK ' BOW V 6,of'r
LAVATORY f k EX �y>•J 'y_ii F Q
ROOF DRAIN ..
SHOWER STALL
SERVICE/MOP SINK — JikN 1'3 2024 -'
TOILET _ —
URINAL t UILDlNG DE PART VIE_NT
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 NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POLICY 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
t 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 I hereby certify that all of the details and information I have submitted or entered regarding this application are true and as ate 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 wit I Pertinent provision of the
Massachusetts State Plumbinglu Code and Chapter 142 of the General Laws.
PLUMBER'S E I� }�AnivioNTQ/2r (&BNSE# / Livi. SIGNATURE
MP JP❑�Jt `" /� RATION 0# PARTNERSHIP❑# LLC 0#
COMPANY NAME �LJ-1OI�F�L-r CORPr- 4- �t nADDRESS 26-/ z ell Kl�
CITY V i-r`� STATE T ZIP 2 7 J TEL 5CG 3
FAX CELL EMAIL C.17 I a P2 1 a an Sria 10
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes Na
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT #
PLAN REVIEW NOTES