HomeMy WebLinkAboutBLDP-18-004342 •
9 . MAS ACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
• ` � CITY a 1/7—" s/ MA DA / i PERMIT*
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D , 1 A OWNER'S NAME `6,YUi/
JOBSITE ADDRESS 1.../•
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL I3 .
PRINT ^ /
CLEARLY NEW:0 RENOVATION: REPLACEMENT:0• PLANS SUBMITTED: YES 0 NO E�'
FIXTURES 1 FLOOR—• BSIA 1 2 3 4 5 6 7 8 9 10 11 '12 13 14
BATHTUB /
CROSS CONNECTION DEVICE L
DEDICATED SPECIAL WASTE SYSTEM ♦9 J
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM `
DEDICATED GRAY WATER SYSTEM F 4(/ • ?j' / •
DEDICATED WATER RECYCLE SYSTEMp Yp,Q _
DISHWASHER J p, �CIe j
DRINKING FOUNTAIN
FOOD DISPOSER \, s /
FLOOR/AREA DRAIN • ~
INTERCEPTOR(INTERIOR) \ c{r
KITCHEN SINK /
LAVATORY oZ .
ROOF DRAIN
SHOWER STALL / _, .
SERVICE I MOP SINK
I TOILET
URINAL
WASHING MACHINE CONNECTION
iWATER HEATER ALL TYPES
WATER PIPING ,
OTHER • _
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INSURANCE COVERAGE: VNO I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES l NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THEPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHERTYPEOF 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
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
Lk! 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 corn.1. ce ' .IL Pertinent provision of the
Massachusetts State PI mbing C de and ChlPter 142 of the General Laws. I / .4
PLUMBER' NAME PLy C LICENSE#1/0/2• // SIGNATURE
MP JP 0 fA ORPORATIONIO0# PARTNERSHIP e/19-//1/4
❑.# LLC 0#
COMPANY NAME /JDA(// rt 1l ADDRESS ' .7 r/�1 j' S Ak-c- q ,,,
CITY /1 STATE. ZIP 02632 TEL S/n-d3� 9 � "��rU 276J
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FAX CELL EMAIL c4IC.kZ! T7 aPitthn6l/ con,
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ROUGH PLUMBING INSPEC'T'ION NOTES
BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
/q 460 (�^C Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $
PERMIT R 1 4
PLAN REVIEW NOTES
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