HomeMy WebLinkAboutBLDP-15-003601 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
Y(= CITY V IAAdWV t i-c-- MA DATE 14 mat PERMIT#O-PP f-60;j�a6/
JOBSITE ADDRESS 11 &OM± l\ j U OWNER'S NAME Dov & N�
OWNER ADDRESS Co4^/t"1(-- TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL[1I—
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:C>a- PLANS SUBMITTED: YES 0 NO El—
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
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK Q
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER'ALLZYPE
WATER PIPING L+ L- 44
OTHER I aaatire F/
OCT1g2 4 D -
zp INSURANCE COVERAGE:
I have Curren iabil troismmm e policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ 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 ❑ 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 Icn.wledge
and that all plumbing work and installations performed under the permit Issued for this application will be in compliance with all Pertinent prtvi Ldehe
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# N-11
ATURE
MPar JP❑ ^ CORP RATION 0# PARTNERSHIP❑'#n, J LLC❑#
COMPANY NAME >)4( M t/f 1 / r��pp ADDRESS - ic O1 W\GUVD c�/��
CITY.S axial c cAr STATE_?v` ZIP t0 Q TELL 4 0 /(J(/
FAX I D(9 CELL EMAIL{O(YM 'COG Med l v tic r ��
3
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: S PERMIT#
PLAN REVIEW NOTES
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