HomeMy WebLinkAboutBLDP-23-11382 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
/ MA DATE I 2- PERMIT " '�`3- //3?2_.
1 I=- CITY V 144 gt
• F JOBS ADDRESS n) ) .rc) R� OWNER'S NAME •
POWNER ADDRESS ��1-s--x-c-c AO TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: ri REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO❑
FIXTURES 1 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
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK • /
LAVATORY 7.--
ROOF DRAIN
SHOWER STALL - / _ --,
SERVICE/MOP SINK _
1 TOILET _
URINALD
V '
+ r
WASHING MACHINE CONNECTION , /
WATER HEATER ALL TYPES / . JUN 21 2023-
WATER PIPING C _
OTHER
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INSURANCE COVERAGE:
{ I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YEPtk, NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY 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
1 Massachusetts General Laws,and that my signature on this permit apta ication waives this requirement.
4=1 •
CHECK ONE ONLY: OWNER ❑ AGENT 0
Z SIGNATURE OF OWNER OR AGENT
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. -- sC_
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PLUMBER'S NAME Rile✓l- 3 '.. I e LICENSE# 30 j 6,5 T SI URE
MP❑ JP n. CORPORATION 0# PARTNERSHIP❑.# LLC❑#
COMPANY NeME ADDRESS ? (0 % .? 7 %
CITY 1-4%/14. vY1 STATE_�.__!LL ZIP 0 7-.C(� TEL 56 '�4/Q"-'"I 1O 2
FAX CELL EMAIL nO✓i COei C7 4i-okou,).C o-si
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
1