HomeMy WebLinkAboutBLDP-24-196 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
0 CITY q C.,/',n4eJ0-. MA DATE a I9,-7 )2,1 PERMIT#, 2 a y,/9C
JOBSITE ADDRESS ST) F...2✓, L_,. p a,,k 82.1 OWNERS NAME (►Je gl-
POWNER ADDRESS TEL FAX______
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL 0—
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES 0 NO 0
FIXTURES-1, FLOOR-, BSM 1 2 3 4 5 6 7 6 9 10 11 12 13 14
BATHTUB - i c. i ta(Ic,c.4) F
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 F 7�_ -
LAVATORY I -_._ _. _
ROOF DRAIN 7r.'�
— ] I , _
SHOWER STALL F�l3 2 ZUZ4
SERVICE/MOP SINK
I TOILET I gUILOI VG DEPART AFNT 1
URINAL B.
WASHING MACHINE CONNECTION r
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 TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY 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
J Massachusetts General Laws,and that my signature on this permit application waives this requirement.
1:-.7. CHECK ONE ONLY: OWNER❑ AGENT❑
SIGNATURE OF OWNER OR AGENT
1-1.1 I hereby certify that all of the details and information I have submitted or entered regarding this application am 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 Plumbing Code and Chapter 142 of the General Laws. i✓iO 02
PLUMBER'S NAME �A/�`r-V.L.', �'�ru( LICENSE# I,'S 't-' W SIGNATURE
MP KK JP 0 CORPORATION 0# PARTNERSHIP❑.# LLC 0#
COMPANY NAME g a r.vc,1 I ?VI?"' ADDRESS SD I as',Sq,�l—,.I1—{' e-/
CITY Mc f fou< STATE ZIP a L-G' '5 TEL r,lc-Sut-t-f 75-7-0
FAX CELL EMAIL Rai cell.pIJu+1.t"y C 0,1...l•co"4-1
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