BLDP-15-002460 •
/ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
-4. CITY )42444,41/71-4 MA DATE /Q// AI PERMIT#I&AoP'/Jr'v019(d
JOBSITE ADDRESS 2 S 1 tte OWNER'S NAME 4/C. .1
P OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL LvS
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:DV 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/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
LAVATORY
ROOF DRAIN •
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING /
OTHER --— —
INSURANCE COVERAGE: Cu t u l ZU I
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES WNO
RUILDING DEPARTMENT
IF YOU CHECKED YES,PLEASE INDICATE THE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELJW1: ��13G
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY El BOND 0 r��.°
OWNER'S INSURANCE WAIVER:lam 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. ca q
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 in o pliance with all Pert t pr 'sion
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME LICENSE#//18'6,7 IGNATURE
MP UT JP❑ CORPORATION 0# PARTNERSHIP 0# ` LLC
1 D LSF
COMPANY NAME L& •
/ DOADDRESS go eck < o��r -/r)g
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CITY " 6 /V STATE a4 1 ZIP 02-0 g TEL �() Ve,7
FAX CELL EMAIL
Ln *1-
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
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