HomeMy WebLinkAboutBLDP-23-11417 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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-= CITY <;';C-1 it1M�'i " iL MA DATE '-2.)."`'� PERMIT# 0R-2-3-I t`71 7
JOBSITE ADDRESS 2-2- -Dr",(s2-I-LA>e-7Ct °4-`-` OWNER'S NAME 1-)Cti_ I
P OWNER ADDRESS C3 7A. i1W.- TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[1:3--"--
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
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 GASIOIUSAND SYSTEM _
DEDICATED GREASE SYSTEM _
DEDICATED GRAY WATER SYSTEM •
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER • _
DRINKING FOUNTAIN
FOOD DISPOSER H
_FLOOR I AREA DRAIN _ _
INTERCEPTOR(INTERIOR) _
KITCHEN SINK
LAVATORY /
1 ROOF DRAIN
I SHOWER STALL 7
SERVICE I MOP SINK
ai TOILET /
URINAL
WASHING MACHINE CONNECTION R E C E I V rE
1 WATER HEATER ALL TYPES
_1 WATER PIPING
Th OTHER 10 t23 ,
BU LDING DEPi-.Rl Mt N I -
tB y -
INSURANCE COVERAGE:
J I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES If(NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
T LIABILITY INSURANCE POUCY ❑'7 y OTHER TYPE OF INDEMNITY ❑ 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 applicationt.waives this requirement.---,..1
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
L'J 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 comilliance with all Pertinet provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. p'
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PLUMBER'S NAME LICENSE# (C 7 . 6 SI NATURE
MP 0 JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME i r I\�� q0? p\U.'✓1bt rJ ADDRESS
CITY i1 11 I< STATE P'r'r ZIP C)2h' TELL 7S7,-Z3 7-
FAX CELL 'T" �I+ f) 6 EMAIL `� r i �ije. \ci (-)•" t' -i ' = (..c),✓1
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