HomeMy WebLinkAboutBLDP-15-005744 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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"1-'2 h CITY ya-r.v� /.Gf 'MA ;DATE -S/20S PERMIT# P-ir. OII W/
JOBSITE ADDRESS 11' I I "n'c.*'i,Ja..G' 4') OWNER'S NAME M,zAe / S1--ec/
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL I�-
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:p' PLANS SUBMITTED: YES❑ NO 0
FIXTURES'2 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/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
f ' '
DRINKING
FOUNTAIN / pe)
DISPOSER `
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) ,
KITCHEN SINK J�
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK _
TOILET
URINAL _
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO ❑
IF YOU CHECKED YES,PLEASE INDICATE
THE E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABWTYINSURANCE POLICY ltd'" OTHER TYPE OF INDEMNITY ❑ BOND ❑
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 ❑ 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 . •mpliance with all Pert -n • . .. . .
Massachusetts State Plumbing Code and Chapter 142
142of the General Laws. / t =� -
PLUMBER'S NAME 8---td 7( h 4 SC fir LICENSE# 364 la `— GNATURE
MP 0 JP kd CORPORATION 0# PARTNERSHIP 0# LLC❑it
COMPANY NAME TO.y,F c.e. .• ADDRESS (O'3 e 1 V C D
CITY °G.-vb fOit STATE, r ZIP%) L -75 TEL
FAX CELLB 'ZZ- 100f EMAIL I MAY 202015
BUIL_ rtinc a
-Gyri F'. �Vr'
BY: i r'/
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