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HomeMy WebLinkAboutBLDP-23-11696 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY T Yr rA,ot4 INMA DATE Sept 5, 1O 3 PERMIT#'�- ( plc-co f 4 � JOBSITE ADDRESS 55 A.'or ih R OWNER'S NAME tU ‘Gk £Uvl41 POWNER ADDRESS IAJe t )°a1111o44 ,, AA ©).b 73 TEL gO-,;" - 1 7 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 50 PRINT CLEARLY NEW:❑ RENOVATION:rip REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO FIXTURES 1. FLOOR-4 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 • DRINKING FOUNTAIN FOOD DISPOSER _ FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) T KITCHEN SINK 4 LAVATORY 1 L — _ ' ` ! ROOF DRAIN _ 1 SHOWER STALL I • _ �; SERVICE I MOP SINK �; uwN�AlR EIdD- WASHING MACHINE CONNECTION _ _ �O WATER HEATER ALL TYPES _ 1 1 265- 1 - 1 WATER PIPING LL i OTHER rs r1 L t h�-at"t-A RThft E N r r j INSURANCE COVERAGE: 1 % 1 I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES% NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABILITY INSURANCE POLICY '5 OTHER TYPE OF INDEMNITY ❑ BOND 0 11` 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. Q CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT 1-1.1 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 knowledge and that all plumbing work and installations performed under the permit issued for this application will be in cornpli nce visio Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 11 PLUMBER'S NAME VA1 Ij �•� th Gyvt Y LICENSE# Id-173 ° NATURE MP EV JP❑ CORPORATION�( 0# PARTNERSHIP Q# LLC El# COMPANY NAME &4na/ r u i s l k tN ADDRESS .5)7 6 iti vq i/t°> pf, CITY a� ��t I Vkou11 STATE AA- ZIP ©c.631t TELOV `%�• f�Je 7 qt FAX CELL EMAIL(14 PT,S K{ K ye GMaj 1. woit ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT p 0 FEE: $ PERMIT# PLAN REVIEW NOTES