HomeMy WebLinkAboutBLDP-24-921 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY Gr� t` . \ ^MA DATE /0' 3 0-0 PERMIT# BCO/P--14-.9 Z./
JOBSITE ADDRESS SN W I�trCS p h OWNER'S NAME sCa ' ✓ 7Grl Pry
OWNER ADDRESS TEL) de 3 QP Cvi/ FAX
TYPE OR OCCUPANCY TYPE COMMERCIALB�EDUCATIONAL❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED:YES❑ NO❑
FIXTURES 7 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 GASIOIUSAND 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 1 MOP SINK
TOILET -7IIRE "{} -
URINAL ��T
WASHING MACHINE CONNECTION :�Q AO.
WATER HEATER ALL TYPES _ I
WATER PIPING putti4l yc noon RIMENT
OTHER
I .
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES nisi) ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCYrd OTHER TYPE OF INDEMNITY 0 BOND 0
OWN R'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
t ss h is General Laws,and that my signature on this permit a lication waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT 0-'
SIGNATURE OF OWNER OR AGENT
i t I hereby certify that all of the details and information I have submitted or entered regarding this application ar- e a- • rate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in • .li-}�►ith all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME
/ .N15 ?Of'- - LICENSE#g 3 301 I SIGNATURE
MP❑ JP LJ CORPORATION 0# PARTNERSHIP❑.# LLC❑#
COMPANY NAME t K .7)1"-wk FJ I ADDRESS CITY WY'."'f STATE, _ ZIP G.f-C ( II TEL 7 7l(�
8 5'C 6Y'(
FAX CELL EMAIL � l
l /l�m fr��i�4Wl�r I,CG✓✓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