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HomeMy WebLinkAboutBLDP-23-11383 ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 1:- 1 T_;_- CITY tea /`AA-0w�� MA DATE (D/obi a3 PERMIT#1 -2 3- //313 JOBSITE ADDRESS Q,(42 /\S.1/4-D/' We OWNER'S NAME,cteiskevt St K ,�P P OWNER ADDRESS iV3 a.ca pL1'f\i ;131 3 J'-ff a 0 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL©— PRINT CLEARLY NEW:❑ RENOVATION: IQ'REPLACEMENT:❑ PLANS SUBMITTED: YES[�NO❑ FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 7 6' 9 10 11 12 13 14 BATHTUB 1 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM _ DEDICATED GAS/OIUSAND 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 SHOWER STALL I . SERVICE I MOP SINK 2 ' 2021 TOILET I Z , URINAL tx— i WASHING MACHINE CONNECTION 3iLo' '; w rt 1' 'ALAnFn,r WATER HEATER ALL TYPES WATER PIPING _ { OTHER _ Sar S ,., k Seti,4 r1? El P AO l t _ INSURANCE COVERAGE: { I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[Q' NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [g-- OTHER TYPE OF INDEMNITY ❑ BOND ❑ 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 application waives this requirement. _ CHECK ONE ONLY: OWNER 0 AGENT 0 Z SIGNATURE OF OWNER OR AGENT LU I hereby certify that all of the details and information I have submitted or entered regarding this application are tru 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 co an th all r'- ; t• . sion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME&to ttf v St kVA al. J'P LICENSE# !O/6,6. S GNATURE MP[Fr JP❑ CORPORATION +�#3O 13 PARTNERSHIP❑.# LLC 0# COMPANY NAME A! t i vt bto v: `U wAo l-j r ADDRESS 3a 0.P "At;P CITY C V✓17 v\ STATE_Ned., ZIP C2) 476c TEL7y 1-(O (D co 7 FAX L t 1 1(Q —O I'7(p CELL33 3(O 2 A EMAIL CLAP't,4J\LL WL.\-7 ( J p WLGat( -CO Ai Ci ysc-/ /ma) 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 • • I