HomeMy WebLinkAboutBLDP-23-11846 If r.., •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
- e—I /'l / PER IT# St '-"ZZ
=11' CITY/N` �� MA DATE .�l ���'� � ,
JOBSITE ADDRESS �J at� Yen /'1 vL OWNER'S NAME xeisa- tAi
POWNER ADDRESS TEL `—r" FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL[3...--------
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT: K-- PLANS SUBMITTED: YES❑ NO l!
FIXTURES 1 FLOOR—► BSM 1 2 3 4 5 6 7 B' 9 10 11 12 13 m
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
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY / -
ROOF DRAIN
I SHOWER STALL .
I SERVICE 1 MOP SINK
I TOILET j ,r
j URINAL I i
WASHING MACHINE CONNECTION I
WATER HEATER ALL TYPES I I, I iP 7 1, 3
1 WATER PIPING I
OTHER
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By 1ll
i 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 E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POLICY 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
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Massachusetts General Laws,and that my signature on this permit ap?lication waives this requiremen
CHECK ONE ONLY: OWNER 0 AGENT 0
Z_ SIGNATURE OF OWNER OR AGENT
LA.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 i compliance with all P nen rovi ions
Massachusetts State Plumbing Code an Chapte 142 of the General Laws.
PLUMBER'S ME,6 N AS LICENSE# leg/ SIGNATURE
MP JP❑ f CO ORATION 0# PARTNERSHIP❑-# _ LLC
COMPANY NAME 1 `D4- �1 t-la2f� ADDRESS PO o 2)�
CITY mot/ �S� Y 1114J/ /? / STATE X ZIP C/;---(2ge- TEL 3 5v 7 3 S '
FAX J 00,2_ % '3 CELLS)2 ,..3 .957EMAIL A f <'/(..9 ,)% Cd 1.41
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
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