HomeMy WebLinkAboutBLDP-23-11929 MASSACHUS ETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBINGM WORK
CITY� i IrI d 41 MA DATE )2- �' Z3 PERMIT#/7o0"_Z3-//9aye
JOBSITE ADDRESS a Krt. Ct ry n t f 1 I c I.\ck'•(OWNERS NAME (.1 c •4 '.
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ID RESIDENTIAL ll�
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:El" PLANS SUBMITTED:YES❑ NO❑
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 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)
KITCHEN SINK
LAVATORY / .4 I __.. _
G
ROOF DRAIN .
SHOWER STALL
SERVICE I MOP SINK 18 102.
TOILET
URINAL o tCrnT„OE,
WASHING MACHINE CONNECTION
4 Try,_NT
WATER HEATER ALL TYPES j
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 12' NO 0
IF YOU CHECKED YES,PLEASE INDICATE TH E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY 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
i Massachusetts General Laws,and that my signature on this permit application waives this requirement.
r CHECK ONE ONLY: OWNER 0 AGENT 0
Z. 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 aar�ee true and accurate to the best of my Im dge
and that all plumbing work a 9installations performed under the permit issued for this application will be in co pliance with ent pfo slop e
Massachusetts State Plumbin Code and Chapter 142 of the General Laws.
PLUMBER'S NAME bi tL,Yt /ILA\ LICENSE# I3/E`-{ SIGNATURE
MP[+ JP 0 CORPORATIONJ , 0# PARTNERSHIP❑# LLC 0#
COMPANY NAME C 't�itm�lYB t 4- 1-LLs1�/c� ADDRESS fit% 1 C. ZZ? -
11 CITY GAS) STATE rYIP/ZIP 0 lam-C�. . TEL
FAX CELL F., _SOI- /73 LL cbp'dthl,ti'1(f 13 It q mult1,C()(n
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