HomeMy WebLinkAboutBLDP-23-11928 MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM PLUMBING WORK
....-_-v9:: CITY .Qr. 01-1-Aleit --f(A..._____ MA DATE PERMIT#,�j L AP Z 3 N J/t
JOBSITE ADDRESS 9y L OWNER'S NAME 4-e C
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY PE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES NO 0
FIXTURES 1 FLOOR-► 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 V ^ D
INTERCEPTOR(INTERIOR) ,
KITCHEN SINK I
LAVATORY / I 1 8 2023
ROOF DRAIN7{ SHOWER STALL INWIM . _ _
SERVICE/MOP SINK BY:.
TOILET /
URINAL
. WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
1I
INSURANCE COVERAGE: �
{ I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES L�J NO 0
IF YOU CHECKED YES,PLEASE INDICATE TH E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY 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 apialication waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT
1-1.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 o n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Q
PLUMBER'S NAME(U ��c1-5 LICENSE#118u 1. SI NATURE
MP[3{-JP❑ CORPORATION 0# PARTNERSHIP❑.# LLC ISitt
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COMPANY NAME �" �rJ� ADDRESS A9k ?C-V---
CITY W , a/wA) STATE G ZIP Duo 6n TEL J'7 rlo7 3 F's3
FAX LXa.2 L W3 CELL,qT ? 3 3S EMAIL lb 6) 'c1%
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