HomeMy WebLinkAboutBLDP-24-338 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
• it. _4 CITY J J VY)(1 v'�1 ,~ 55 I MA DATE 4 5� 1 PERMIT# $Li 2- '- 35.;
JOBSITE ADDRESS 35 [-I 1Jl t)1%$ A3iitJ OWNER'S NAME kV i CFI I n� In 4 0 111 4)1u fry
POWNER ADDRESS _ TEL J FAX 1
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 4
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CLEARLY NEW:13 RENOVATION:Q REPLACEMENT:❑ PLANS SUBMITTED:.YES❑ NO❑
FIXTURES 7 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB •
CROSS CONNECTION DEVICE 1 'uI ,
DEDICATED SPECIAL WASTE SYSTEM ,1 I I :1 I( 1 I '
DEDICATED GAS/OIL/SAND SYSTEM ROOK - t
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DEDICATED GREASE SYSTEM ' t- :
DEDICATED GRAY WATER SYSTEM ;; _ ; _, __
DEDICATED WATER RECYCLE SYSTEM 1' . 1; 1 I I
DISHWASHER MR, I NM MI NM NM UN MI
DRINKING FOUNTAIN _ _.1., _ ;11pljt nj
FOOD DISPOSER 1111111111111111L1M
FLOOR I AREA DRAIN _11111,11/1• ,
INTERCEPTOR(INTERIOR) i. � '
KITCHEN SINK HIMIEWINI M
LAVATORY 111 �� �.
11, h . J .iJ1111111,111111 NMI NM
ROOF DRAIN _
SHOWER STALL �', ��, i ;��
SERVICE/MOP SINK Mt1TOILETURINAL Egg , I !it
WASHING MACHINE CONNECTION1111,111§MIRIMIM
_WATER HEATER ALL TYPES - I - - i lin_
WATER PIPING t, 1 I�..-�;OTHER ___(•�1; EkoYr ��-' yyrl - 1 1 I in
__ _______._ ICI I !i
i_. . � I i. _I! �. ' 1 �.-. _ �■r
INSURANCE COVERAGE: R / 4 •
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch :- S -tie
+IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW, PR 05 2024
LIABILITY INSURANCE POLICY®- OTHER TYPE OF INDEMNITY❑ BOND ❑ 96 S I'' DJ1NR
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage require b�Y ttapterG 142 of the DEPA TMENT
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application ar accurate to the best of m nowledge .
and that all plumbing work and installations performed under the permit issued for this application will be i f nce with all Pertin provis' of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME 7 1kowl 0,6 tv(clot/ I LICENSE# 160 11 SIGN TURE •
MP®, JP❑ CORPORATION 'ks/ ,PARTNERSHIPD# LLC❑#_
COMPANY NAME ler, 471. p
I ADDRESS /0 0 io< `jy
CITY 0 t ti c 1 STATE IMQ- ZIP 02/6 f I TEL (qj , -90g - 903 6
FAX CELL EMAIL b LA u/ _a Ca G WI n{' •CO el-- '