HomeMy WebLinkAboutBLDP-23-11817 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
-,-_.;9- CITY & wtrrH PORT( MA DATE /6-3C)-2.623 PERMIT#[5'-eP-z t-i t y I?
JOBSITE ADDRESS .2-7 Fes[' 1-G-I OWNERS NAME ( y
POWNER ADDRESS 74 F 4e6ST G-4-1-Z Yih°MouiN PoC(TEL FAX_
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL[2
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CLEARLY NEW:Mv.- RENOVATION:0 REPLACEMENT:❑ 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/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM —
DEDICATED GRAY WATER SYSTEM _
DEDICATED WATER RECYCLE SYSTEM _
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK -
LAVATORY -
ROOF DRAIN
SHOWER STALL •
R r_ d g
SERVICE/MOP SINK
TOILET
�S; URINAL [OCT 3Q 2023 t
WASHING MACHINE CONNECTION J
'ZI WATER HEATER ALL TYPES B.) it cGHFf^oTn hi
WATER PIPING -
p%�I OTHER
i4. INSURANCE COVERAGE: -
Z I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Id NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 2 OTHER TYPE OF INDEMNITY 0 BOND❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
J Massachusetts General Laws,and that my signature on this permit application waives this requirement.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER❑ AGENT❑
LtI 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 II Pertinent pro Ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME ivAY4)tC 'mmDS LICENSE# 3/5$7 _ " NATURE
MP 0 JP CORPORATION❑# PARTNERSHIP❑.# LLC 0#
COMPANY NAME kmm/freD5 I A113/ro'G i//e4f/a'6 ADDRESS z6 B0Arr/NG GA.J/E
CITY &L/637r,V ej Io1 u rF/ STATE ilt44 ZIP 02-6 73 TEL 7 PI-3'36 ZS-3
FAX CELL 77`7'8'36'Z5-3' EMAIL l,(i,lYAierffG PuJni8Eet6"6.-f/6.e'(M
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