Loading...
HomeMy WebLinkAboutBLDP-26-137 f R • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK --i_— . CITY /-f f�-r�W c'-rl f MA DATE PERMIT#A.y''"Z "/37 JOBSITE ADDRESS '3 G co (l_.F�A g PpOWNER'S NAME `4.4 POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL©-'"----.--- PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ 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 " ,><A ' �,._ k. DEDICATED GREASE SYSTEM L _ . DEDICATED GRAY WATER DEDICATED WATERRECY SYSTEM RECYCLE 1 •FEB 17 N26 DISHWASHER • t atr?Gar_' :-,7 DRINKING FOUNTAIN 3Y _ FOOD DISPOSER FLOOR/AREA DRAIN _ INTERCEPTOR(INTERIOR) , KITCHEN SINK _ LAVATORY - ': ROOF DRAIN SHOWER STALL • , SERVICE/MOP SINK I TOILET URINAL ' . i WASHING MACHINE CONNECTION WATER HEATER ALL TYPES �--7 _ _ WATER PIPING _ OTHER 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 THETY F COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND 0 i OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the t Massachusetts General Laws,and that my signature on this permit apQiication waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT 0 SIGNATURE OF OWNER OR AGENT Vi I hereby certify that all of the details and information I have submitted or entered regarding this application are true nd 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 comp' ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. S L/ PLUMBER'S NAME 3 v pi J -,&/1 tV l' - LICENSE# /5/.g C SIGNATURE MP JP CORPORATION /❑# PARTNERSHIP�E L # ,� / LC 0# COMPANY NAME 170�.// [ A- / t F! 1 ADDRESS<=z./ �AV / i /OA V lf 4 P CITY Mri---nit0V TPit STATE t4 ZIP ')Z 67 5 TEL `, 0$5 6D 37 g'5 FAX CELL EMAIL hril Gift 0 Mel 0or 46 S 1.,w4 if 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 • • r i I1 x la° '',--- , TIi. um- og ... 1:30 ( July 14 121-18PM 4„Ltvt,. v. .. .0 ,,.-,,,,,;.,,--',...-:: ',Yi,',...-.:,'• ..', :4,: ,-. =,,,v _,.,'.-'.:,',,,,, , ., • , .-:,,,''. '. . , , , i , . .,..-,.. ,,,,,,,,,,:,,,,i,r,, ,,-_.,,,,'. ., ,•,,.. : ,- , ,.., ,_ ' - •-,,v,..,..;ct1.,b . ,.,,. • , , .., ... ''v.141--:44.- '',. ''',_:A1`,,:„ , ', ':,'''; "„..' ;'-,..(`;?-';',-,!:" {kv:•L:"...p.i.L4*01,..-4'it;',.::1,,.,-y,...',..L,,.'.i. „ , ...: • . • , ' , ' . 4,001P„ti.'.4 .',-;;;:.11,'' .:::''.:. 4APC.;', p,:"`;'.j,,,','.4,' ''',f,'‘:'''''Oefl,:'-',''' ',-• '' - 1 -..-7 - , LI) ,.... ,, ,.... cl (t) mil- r.T3 i .ie7 , •