HomeMy WebLinkAboutBLDP-24-475 3AZ_
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT/zv
TO ERFORM PLUMBING WORK
= a CITY oV'�1 MA DATE 5-i/ PERMIT# 3 f-DP-2 k-L1 7 S.
JOBSITE ADDRESS J 0 (AiI.7G..7 el TH OWNERS NAME P��L. _
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL❑ RESIDENTIAL 0
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:D""------ PLANS SUBMITTED:YES❑ NO 0
FIXTURES 7 FLOOR-, BSM 1 2 3 4 5 6 7 B 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 Q E E I v_E 6F
FLOOR/AREA DRAIN J
INTERCEPTOR(INTERIOR) _
KITCHEN SINK _ Y L 20 _ _
LAVATORY E_ _ r
ROOF DRAIN UILD NG DE`PARTM=T 1 _
SHOWER STALL " 7
SERVICE/MOP SINK
I 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 NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POUCY)J�' OTHER TYPE OF INDEMNITY El 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.
rCHECK ONE ONLY: OWNER❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
1-I 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 comp•nce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME D/61-0M ?Ql/51 V E# /51(1‘ SIGNATURE
MP JP /�f CORPORATION
�,j❑# PARTNERSHIP LLC�#
COMPANY NAME
v � /O 4 �y�ADDRESS/� 55 ? `` %V 1� trrjS
/�
CITY Yfrifl---OA STATE I T ZIP t/Z4 J TEL — I-7-5 3
FAX CELL EMAI a o /05
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT n I I
FEE: $ PERMIT #
PLAN REVIEW NOTES