HomeMy WebLinkAboutBLDP-23-11398 `k). , MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY ?`V 1 Cl�/TNIQCIvt'►A MA DATE IU/' i/�(.?/ PERMIT .-2 3-//3 9?
JOBSITE ADDRESS 9- intricqh4-iin fe e h/Gt e_.° OWNER'S NAME 7)IIA, ' �2
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:ill. REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO
FIXTURES 7 FLOOR—+ 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/OILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM •
DEDICATED WATER RECYCLE SYSTEM y
DISHWASHER •
DRINKING FOUNTAIN _
FOOD DISPOSER
FLOOR/AREA DRAIN _
INTERCEPTOR(INTERIOR)
KITCHEN SINK
E
LAVATORY a. _... .... V D
} ROOF DRAIN _ 1 $1
SHOWER STALL $ L J II 2 i 2023
SERVICE/MOP SINK _ �(}V_
TOILET , 1 1 • 1)1--NA rig NT r
URINAL L L
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING a _
OTHER
INSURANCE COVERAGE: iN0} I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0
IF YOU CHECKED YES,PLEASE INDICATE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY 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
1 Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
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. ®
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PLUMBER'S NAME f I f jC�;' t t�1r'e LICENSE#-31 /CY SIGNATURE
MP❑ JP Ni CORPORATION 0# PARTNERSHIP 0# LLC 0#
COMPANY NAME l' l OC6 P k if ADDRESS 5- Co([ , i� S —
CITY tgn=t- STATE 6�� ZIP 0t 6715 V TEL VI VS-(15 !
FAX CELL EMAIL (11 1 I. d5du-iaL1e cork
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSP CTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT#
PLAN REVIEW NOTES