HomeMy WebLinkAboutBLDP-15-001739 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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is _ CITY CI-I -�nouf le- MA DATE /0— 1 If PERMIT# /.ADO If"� /7W
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JOBSITE AD
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OWNER ADDRESS 3 ` ��� �6 r � A �TEL 3/L� �� ��
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES 0 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/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK /f7ei livOa,
LAVATORY On mei
ROOF DRAIN 7$t1, 2f/evra.e f
SHOWER STALL
SERVICE/MOP SINK 1,14-170"
G�-
TOILET / r
URINAL
WASHING MACHINE CONNECTION I • - /- -
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 0 NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUC ] 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 co with all Pertinent provision of th
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE#46,?A SIGNATURE
MP 0 JPa CORPORATION( 0# PARTNERSHIP 0# LLC 0#
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COMPANY NAME
�Gett. tA. `404— ADDRESS V?tor e. vII- ��'.1 — N'—.
I/A to U.� ' '.
Cl��nr w� STATE Y'"! ZIP o Fra- -6, - i 2 •6
FAX CELL EMAIL I nrT 02 2014 I
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT#
PLAN REVIEW NOTES
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