HomeMy WebLinkAboutBLDP-23-11887 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY plefAtAlni4-
MA DATE /77a3 PERMIT* dl-1P' Z 3 _, l l Pi 7
JOBSITE ADDRESS 5' 7)A S Ie e I OWNER'S NAME)(t/L '4ub t{'
OWNER ADDRESS I ALLBG-� xzie/eA /I/e / TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO❑
FIXTURES 1 FLOOR-4 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/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM •
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN _
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY / •
ROOF DRAIN
SHOWER STALL •
SERVICE/MOP SINK
i TOILET
URINAL
WASHING MACHINE CONNECTION
REF- D
WATER HEATER ALL TYPES C �~ ' V_�
WATER PIPING
OTHER 17 242-1
1 BUILUiNGD[J{Al THE T
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY .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 apQfication waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
1-1.1 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 compli ce with all Pertinent provisi n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# ` 6 "f/!.-, CRA4RE
MP 1-2 .1P❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME C '"T ADDRESS L
CITY STATE PA- ZIP C'a``ylS-3 TELC?FAX CELL EMAIL .J±i a C,4 i- 101 I C/d vcf. Cej—
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