HomeMy WebLinkAboutBLDP-24-173 `. ` H
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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-�;l= �� CITY� �ROto•r �1 I MA DATE �.� -� /-> �y �PERMIT#O L OP-2`?—/7 3
JOBSITE ADDRESS ! ;F: rl7n 5`7� I OWNER'S NAME (j.Cei y ide,e I
1 OWNER ADDRESS I TEL 'FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL 8
PRINT
CLEARLY NEW:ID RENOVATION:a REPLACEMENT:0 PLANS SUBMITTED: YES❑ NOD
FIXTURES 7 FLOOR 9 10WIWI BATHTUBS I. . -;VIIIIIII!
CROSS CONNECTION DEVICE Imo_1.1'OM IIII.M.111.11ANI MR OM M '
DEDICATED SPECIAL WASTE SYSTEM mum:pitMOM IMIIIIIIIININWHIONIMIUNIESIIICIMI.IMO
DEDICATED GAS/OIUSAND SYSTEM gorilliM., jiimpitilitoursurin.111111111111Ntallii
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DEDICATED GREASE SYSTEM MR MI MEI .i. i� '
DEDICATED GRAY WATER SYSTEM anspipsaft001110.____� 0111
DEDICATED WATER RECYCLE SYSTEM ,porsipss,I i rMIPPIRl ,INI ,' ,ON1:s.
DISHWASHER ��_ :.. i1 —.'_'_:
DRINKING FOUNTAIN _�'I0 1 1�1 !WW �I 'I
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FOOD DISPOSER I I' �W 1 ' 1 WININI NM
FLOOR I AREA DRAIN .' Ir_. _� � MI_«'
INTERCEPTOR(INTERIOR NOM ��, !It•a' I1=1Mi.m!, riiiiil
KITCHEN SINKf.Wi I -- —MOMBWOMirM1
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ROOF DRAIN �I, Mf
SHOWER STALL Ihi ; 1 _' -i
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SERVICE I MOP SINK lIMIWOWIliVentWeri.10114:iiiiiiiiiiiii:WWW,M1
TOILET 111111,111111111111111.0101011111MMIUMMIRMINIMPRIMMOMMF'
URINAL PillitillitMIMIRMIIIMEIEftillitill111111
WASHING MACHINE CONNECTION j; liJ I . ..... ;, : I +��- �.ipu"!"m jIMION I m
WATER HEATER ALL TYPES ' i ' 'iI
WATER PIPING ' i l� ;! I ill
111.11.11 M.NMI
OTHER _ __. I��l � �� - - '� �M � �'I
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WIMJIMOWINIIIIIIIMICOMMinailifilIWIMIffiiiiia—mil
INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL .4t - ' `• V�, L
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY aOTHER TYPE OF INDEMNITY IDBOND 0 FEB 15 2024
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the _
Massachusetts General Laws,and that my signature on this permit application waives this requirement. 1 u u i L_) L. u � 1 r<r M E NT
_ CHECK ONE ONLY: OWNER ❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the detats 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 Plumping Code and Chapter 142 of the General Laws. n�4 �� ! ,
PLUMBER'S NAME I2:Y l/l/S'42��rI6/Lt ILICENSE# /'/',JC-i` I // SIGNA
MP ' JP® CORPORATION Eli .- -?'/ 'PARTNERSHIP ID# LLC Q# I
COMPANY NAME i ft CiM/S L ADDRESS f (.74W, —
CITY / d .%1. I STATE'ma I ZIP e a 23 , TEL 7 7`7(.3..7 6 6"7617y
FAX I ~ I CELL I = I EMAIL 4y¢�9/1e/1/r1SA7 e d'Ol• ff.-4
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE:S PERMIT#
PLAN REVIEW NOTES
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