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HomeMy WebLinkAboutBLDP-23-11965 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ;Ili";:• CITY a MA DATE \ / \ /2'3 PERMIT# 8LDf 23" //'711 JOBSITE ADDRESS S ..cre\, OWNER'S NAME 1 \—c& POWNER ADDRESS Gi vcci.k TEL�= TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL LI PRINT CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:II PLANS SUBMITTED: YES 0 NO❑ FIXTURES 1 FLOOR—► BSM 1 2 3 4 5 6 7 8' 9 10 11 12 13 14 BATHTUB 1 _ CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM 1 DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER • ___ DRINKING FOUNTAIN al FOOD DISPOSER I _,_.._.— ="'' ,.' 1 FLOOR/AREA DRAIN 'c _. . • '- IA INTERCEPTOR(INTERIOR) _ i, KITCHEN SINK i �1:� 2,' A LAVATORY t _ - \ `, MEN ROOF DRAIN Ai,`�o'N ''� SHOWER STALL ' SERVICE I MOP SINK '7 _ _ TOILET \ URINAL WASHING MACHINE CONNECTION _ WATER HEATER ALL TYPES WATER PIPING OTHER r 1 1-- _ , INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES IZ NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY (]f OTHER TYPE OF INDEMNITY 0 BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 1 Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT L: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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ` PLUMBER'S NAME S\-—. LICENSE# G . �Z. SIGNATURE MP 0 JP i CORPORATION 0# PARTNERSHIP❑.# LLC V# COMPANY NAME dQS •.N.�\-,\•c.\C 'c ` .� ADDRESS \ .,`o X- \` — `s STATE '\ ZIP ©`c.�G �1 CITY TEL FAX CELL7� 2�`2�`k EMAIL \- J� \5 @.\\�iQ- - C�� 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 • '' DIVISION OF OCCURAT",ONAL LICENSURE ,dogsy • • 44 ... 33760 ' , P` M..:; [NU` LICENSE NUMBER EXPIRATION DATE SERAL.NUMBER