HomeMy WebLinkAboutBLDP-17-00577 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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_ _F= MA DATE /`I// PERMIT#�J�n'�7�OOy�TJ
JOBSITE ADDRESS Z-y yr/t - ,-- 5 f" OWNER'S NAME
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL S—
PRINT
CLEARLY NEW:2" RENOVATION:[u,- REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
FIXTURES 1 FLOOR-+ BSM 1 2 3 4 5 6 7 B 9 10 11 12 '.13 14
BATHTUB I
CROSS CONNECTION DEVICE _
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM _
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER I •
DRINKING FOUNTAIN
FOOD DISPOSER ' _
FLOOR/AREA DRAIN .,---.-. :a t: td 4
INTERCEPTOR(INTERIOR) 4
KITCHEN SINK I \TIP
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LAVATORY 2, I 0 I.� L%,,,4n il
ROOF DRAIN ti
SHOWER STALL 8 ` :'op.T\ l
SERVICE I MOP SINK ,\A010.•
I TOILET Z 1 .v_/
URINAL ✓
. i WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES I
WATER PIPING I
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESIZ NO 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY LI 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 ap?lication waives this requirement.
.
CHECK ONE ONLY: OWNER 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT
141 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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ��
PLUMBER'S NAME 5-cJ To.„4n//i LICENSE# 306,y8. SIGNATURE
MP❑ JP(E- CORPORATION 0# PARTNERSHIP 0# LLC❑#
COMPANY NAME bet,, 4",fid+' n,-
6,9 ADDRESS 10 3 b-i.-, ,'+ -, S
CITYJ., /4 `4+ -f n STATE { 4 ZIP_ Z 6 7 C TEL
FAX CELL S1T- 1ZZ- L/p6/ EMAIL
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ROUGH PLUMBING INSPECTION NOTES pELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ 0 FP
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RIC/ "]L w as' O FEE: $ PERMIT U ArePLAN REVIEW NOTES II) 7 •
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