HomeMy WebLinkAboutBLDP-25-469 MASSACHUSTTS UNIFORM APPLICATION FORA P MITT PERFORM PLUMBING WORK
-• I � CITYW ` fA dz) MA DATE 2�PERMIT# BCb P-2`'k64
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JOBSITE ADDRESS �6 �j,°c�GGi� OWNERS NAME 1//D O ��f1/l_�1-
POWNER ADDRESS 77T TEL 3 2� C,S/ 1?FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL❑ RESIDENTIAL 6
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:VI PLANS SUBMITTED:YESki 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 GAS/OILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM _ -
DISHWASHER R F
DRINKING FOUNTAIN y [ — --
FOOD DISPOSER _ Wu a_. �r�
FLOOR/AREA DRAIN Jv" V4 2025-
INTERCEPTORSINK NTERIOR) LU! DING DEP r —
_ e KITCHEN SINK / L
LAVATORY rf _____I _
ROOF DRAIN _ _
I SHOWER STALL / -
SERVICE I MOP SINK
TOILET / _
URINAL
WASHING MACHINE CONNECTION _
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 OE NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POUCY tca 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.
T CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
'Li 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 at Pertinent provision of the
Massachusetts State PlumbingCode and Chapter 142 of General Laws. I ss`-G/ a ��r
PLUMBER'S NAME I LICENS(E�# N....".... Q • SIGNATURE
MP❑ JP K CORPORATION 0# (fro r."PARTNERSHIP❑.# r LLC 0#
COMPAN NAME I "' CA- rib P 1} L ADDRESS 31 ��I A LC,[,✓) Atte. _
CITY ( n n I S STATE ZIP Q Z.60/ TEL77e y4,-y/7.T.
FAX CELL EMAIL PTG ®c •
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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