HomeMy WebLinkAboutBLDP-18-000306 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBINGU� � WORK
rLre CITY )/�.t&wt ocs tpnAi MA DATE 7 - 1 �2- 17 PERMIT 0.�Y-DP a49SC
JOBSITE ADDRESS 902 2 gn 1.6 A A OWNER'S NAME G' C(10TW o ( ( c_
P OWNER ADDRESS U'(t' 6— TEL FAX'
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TYPE OR OCCUPANCY TYPE COMMERCIALLY EDUCATIONAL 0 RESIDENTIAL 0
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CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
FIXTURES'1 FLOOR-a 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 i
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
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DEDICATED WATER RECYCLE SYSTEM -
DISHWASHER •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN _ _ _
INTERCEPTOR(INTERIOR)
KITCHEN SINK -- - - --- -
LAVATORY 6. . l i Cl ( c'3 i tI a . , i
ROOF DRAIN I r I
SHOWER STALL I I•
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SERVICE/MOP SINK 9 1 JUL 12 IBiD , ! -
TOILET 6 I I '
URINAL I Hi r°
WASHING MACHINE CONNECTION 1." _ C/lV _: ( __ ,
WATER HEATER ALL TYPES
WATER PIPING 1 _
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES IE -1:1; 0
IF YOU CHECKED YES,PLEASE INDICATE THE PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY 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.
et CHECK ONE ONLY: OWNER ❑ AGENT 0
Z SIGNATURE OF OWNER OR AGENT
1.4.1 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 corn ' ce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /�
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PLUMBER'S NAME LICENSE#3a. '73• SIGNATURE
MP❑ JP L1'/ CORPORATION❑# PARTNERSHIP IP 0# //'' LLC❑#
COMPANY NAME ADDRESS 1f7 C2(1/&.lh g4-44.-t.iP.y Roct4
CITY _c rf 1.. )/LLNGvt0UL4L STATE 04..4 ZIP 62-660 TEL .Soft S60.37if
FAX CELL EMAIL
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ROUGH PLUMBING INSPEC/T�IIOO/N NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
e&/.71 / Yes No
Aie/ J THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ r-- 6/A /
FEE: $ PERMIT It '117(
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PLAN REVIEW NOTES � i�-r 7/
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