HomeMy WebLinkAboutBLDP-16-001110 •
tY - � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY_ kt MA DATE 6 12( ( 1 -7c
PERMIT# PY-0-g 'e0/9/61
JOBSITE ADDRESS I V _ , i -�• OWNER'S NAME H ‘.h P 1 G °AN
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OWNER ADDRESSL A.I
• ., , stT_EL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL �' EDUCATI6NAL ❑ RESIDENTIAL 0
PRINT e
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES❑ NO,
FIXTURES 1 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/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN r _--••
FOOD DISPOSER __ .__.
FLOOR/AREA DRAIN i" 1i I- r i I /
INTERCEPTOR(INTER�OItoccei3- �
KITCHEN SINK ,{C.3� I (DU
LAVATORY ' AMA 2b £015
ROOFDRAINI (_..--/H/
SHOWER STALL- r;r 7:P . rrl, : r
SERVICE I MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION _
WATER HEATER ALL TYPES
WATER PIPING D
OTHER 6,,rva d ( SOt'�i) 1 _
v J INSURANCE COVERAGE:
•
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YECNO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTYINSURANCE POUCY OTHER TYPE OF INDEMNITY ❑ BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
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
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 compli e with all P rtin nt provision of the
Massachusetts State PlumbingbiCode and Chapter 142 of the General Laws. /// C
PLUMBER'S NAME /y��lkj �, LICENSE#2'I(o' C/7yGNATURE
MP 0 JP / I ✓✓�C O PORAT`ION❑# PARTNERSHIP 0#n _ L L�❑#
COMPANY NAME 1 64,-/FP K` V -1717 ADDRESS /7 3 q/2e'l //�.S
CITY MACiret v STd i44 ZIP 42642 1�v TELSZ ‘9& Sign)'
FAX 7 CELL EMAIL Afir • '. I/✓ ,
1_,R1}'
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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
a
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