HomeMy WebLinkAboutBLDP-25-696 PaA 6 ca5,ti -11
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY 0✓14 j� : vP zs-ld9b
_ hf= MA DATE 7/ L l PERMIT#
JOBSITEADDRESSS /U/DO�/��/ OWNERS NAME - 11(e%�ifeae
P OWNER ADDRESS , ecl, ilio//ep/_ TEL._0�36�yklWAX__
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TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: PLACEMENT:0 PLANS SUBMITTED:YES❑ NO 0
FIXTURES 1 FLOOR-, ISM 1 2 3 4 5 6 7 8 9 10 11 12 13 14-
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM L
DEDICATED GAS/OIUSAND SYSTEM --
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER ,
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK 1 -
LAVATORY
ROOF DRAIN
SHOWER STALL ,sue
SERVICE/MOP SINK - -
TOILET "
URINAL -
WASHING MACHINE CONNECTION I r
WATER HEATER ALL TYPES I ilC 1
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 THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POLICY 0 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
1 Massachusetts General Laws,and that my signature on this permit application waives this requirement.
3----_- SIGNATURE
ONE ONLY: OWNER❑ AGENT❑
SIGNATURE OF OWNER OR AGENT
LLI I hereby certify that all of the details and information I have submitted or entered regarding this application are true and a to to th�knowledge
and that all plumbing work and Installations performed under the permit issued for this application will be in oomph ne ' n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S hi€;C/� // Sr�p LICENSE# SI RE
MP JP❑ CORPORATION 0# PARTNERSHIP❑.# LLC 0#
COMPANY NAME 742577/4+-1 aj� J, 6/2/xe./' ADDRESS, ./.1 ,f�
CITY? A / STATE/-"/ ZIP d7.SL3 T TEL, Oe"-- al
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FAX CELL_( ?5i-J-6.F->-//1- EMAIL CZ 421 j9 r-(.1 (i 5,at1Z1 f`
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT n n
FEE: $ PERMIT #
PLAN REVIEW NOTES