HomeMy WebLinkAboutBLDP-23-11375 MASSACHUSETTS UNIFORM APPLICATION FOR E IT TO PERFORM PLUMBING WORK
_-_ CITY / C Ul I MA DATE Z.- PERMIT#Rwp-
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JOBSITE ADDRESS /// /(-C6 Lc) Y I kain OWNER'S- NAME DgA I.t.✓ Oo ( Q C 07-7
OWNER ADDRESS CS' 72/ TEL70/ 7('Z FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL[6..
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED:YES 0 NO g
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 6' 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 •
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK rt.ce_ E S d Fi D
TOILET
URINAL — *- 1dN 2 0 2023! I
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES -
WATER PIPING - - - 2U LCItIU
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Vd—NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY 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
i Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
LU 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 with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �-/ �/ Q
PLUMBER'S NAME LIC^ENSE#// SIGNATURE
MP 0 JP Fl CORPORATIONRP� 0# Pro P PARTNERSHIP❑.# LLC❑#
COMPANY N E f (/J � t c� 0 " 67& ADDRESS -3 7� r9.�1----/'7 "✓"r n',
CITY I 4 ( / STATE ZIP v L6)/ TEL 77 1v Y/2 FAX
FAX CELL EMAIL 5•7 l &/"✓t' cJ rr
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