HomeMy WebLinkAboutBLDP-23-11605 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
'i CITY tAJ r S f 7 anmom4, MA DATE V ; / PERMIT#,( LDP-23-//V:5-
JOBSITE ADDRESS NO frt&Gr i-'IAUI[1' re. anti 13f OWNER'S NAME FS4ieF'1 C��[/P�nil
POWNER ADDRESS3VO It.-elf L$(LtyiA (d GV14 17/--- TEL 17 0K5"239S FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Ec
PRINT / ��,/
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO L�
FIXTURES 1 FLOOR—+ BSM 1 2 3 4 5 6 7 6' 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 I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
^ LAVATORY • - - __,
ROOF DRAIN R EC F II,V t D
SHOWER STALL _ ) - ,
SERVICE 1 MOP SINK _ ��nn
23
TOILET �� [U
URINAL
. WASHING MACHINE CONNECTION BUILDING DEP\I-2I MAN
WATER HEATER ALL TYPES i. BY
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 P( NO 0
IF YOU CHECKED YES,PLEASE INDICATE E TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY 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
� Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT 0
Z SIGNATURE OF OWNER OR AGENT
L‘.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.PLUMBER'S NAME 144444E1 ) £0414 lq41 LICENSE#3L/3 egiy% SIG ATURE
MP❑ JP LJ CORPORATION 0# PARTNERSHIP❑.# LLC 0#
COMPANY NAME Mali- edenvIr r es,- # ADDRESS 5 college 5-4-
CITY £i) + _/acm ,* STATE A ' ZIP O2C7 j TEL RiO —e$5-1(3'J
FAX CELL EMAIL bit ent6t7Gn"liio5GvRiera t .eau
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