HomeMy WebLinkAboutBLDP-25-244 /SP-lJD
MASSACHUSETTS UNIFORM1APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
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1€�_• CITY S yG/`m OK I yr h MA DATE �_f� �� PERMIT#II�nOR L)"- L y y
JOBSITE ADDRESS 8 v re�W W L
kan(1 Q I- OWNERS NAME'3-.3e C.0
P I .
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO 0
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FIXTURES 1. FLOOR BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14
BATHTUB r _
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM _ _
DEDICATED GAS/01USAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM 1
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER _ _ _ _
FLOOR I AREA DRAIN _ _ _ _ _
INTERCEPTOR(INTERIOR) _ _
KITCHEN SINK
LAVATORY
i ROOF DRAIN
SHOWER STALL f _ _
SERVICE/MOP SINK
I TOILET . - -
1 URINAL _ _ _
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES i
WATER PIPING 2( _ _ _
I OTHER
INSURANCE COVERAGE: ,,/
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES U NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY OTHER TYPE OF INDEMNITY 0 BOND 0
' 0 ER',,'SURANCE WAIVER:I am aware that the licensee do s not have the insurance coverage required by Chapter 142 of the
a7.a setts Gene ."s,and that my si r is permit application waives this requirement.
2 Ar
CHECK ONE ONLY: OWNER' AGENT Ift—
/.GNATURE OF OWNER OR AGENT
s::.! I hereby certify that all of the details and information I have submitted or entered regarding this application tr 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 m ante with erti nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. __--------
PLUMBERS NAME LICENSE# f('3De4 IGNATURE
MP❑ JP p 1-1-
t /`CORPORATION 0# PARTNERSHIP❑.# LLC 0
COMPANY NAME Pa` - \ 11 �A ADDRESS 3- S''� TO 5>•0�
CITY HYC."".. /f7 STATE,',1'IA ZIP 06-CO( TEL
FAX CELL? CJ 7 Y >C. 6 vc,( EMAIL/)*"/r.c'1lb-9"-' 6-5 ,(. L'Owl
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