HomeMy WebLinkAboutBLDP-19-000203 •
MASSACHUSETTS UNIFORM APPLJCATION FOR� A PERMIT TO PERFORM PLUMBINGBIWORK
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MA DATE - I ) - `$ PERMTr#�,Jr�419-IOO#q
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JOBSrrE ADDRESS I ( _ 1lN twI� ER
OO C OWNERS NAME Mac'h-e\tkq
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 • RESIDENTIAL V
PRINT
CLEARLY NEW ID RENOVATION:[' REPLACEMENT:❑' PLANS SUBMITTED: YES❑ NO 0
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 19 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 1 MOP SINK
TOILET I
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
R E l
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of M L .142. YES NO 0
IF YDU CHECKED YES,PLEASE INDICATE THE E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELO 'JUL 11 2018
UABILITYWSURAIJCEPOUCY OTHERTYPEOFINDEMNITY 0 BOND 0 BUISgI,� biTM��, co
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
1�
SIGNATURE OF OWNER OR AGENT
L:l I hereby certify that all of the details and Information I have submitted or entered regarding this applicafon are e -. . - e to the best of my Imowledge
and that all plumbing work and Installations performed under the permt issued for this application will be In •.mpta r.. -,-'•-• ••••'.. . . ... .. . I I e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 2
PLUMBERS NAMEI:h � ` �t LICENSE# 13 � SIGNATURE
MP ric JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COM W NAAECrn r I LJJ sftJ+ 1 �'6 ADDRESS TO -75Q
CITY o+ Q 01(0- — fSTATE Ite gff ZIP ceJLI� TEL �i'U 112-
FAX CELL�b�-9ZZ— f 22) EMAIL a6
ROUGH PLUMBING INSPECI-ION NOTES PELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
P101-- A-G di( THIS APPLICATION SERVES AS THE PERMIT 171
4/ 7////8 FEE: $ PERMIT 11 - P
PLAN REYIEW NOTES
C OF • i n71/r