HomeMy WebLinkAboutBLDP-15-000379 . .. MASSACHUSETTS�( t�t� UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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JOBSITE ADDRESS (J to T,A1�k S4- VOWNER'SNAME J4t&3 IALLtI SCO
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R OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONIA ❑I IRESIDSTAL W
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- Y NEN:❑ RENOVATION:❑ PE'LACEMEN PLANS SUBMITTED: YES 0
NO 0
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DEDICATE)GAS/OIL/SANDSYS I I I I I I I I
DEDICATED GREASE SYS I I I I I I I I
DEDICATD GRAY WATER SYS I I I I I I I I
DEDICATED WATER RECYCLE SYS I I I I I I I
DRINKING FOUNTAIN
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DISHWASHER I I / I I I I I I_ I •
FOOD DISPOSER I I I
FLOOR/AREA DRAW
INTERCEPTOR(INTEPJOR) I I I I I I I •
KITCHEN SINK I I I I I I I I
LAVATORY-_. I I I I I .1 I I I
1 ROOF DRAIN- I I I I I I I I I
SHOWER STALL I I I I 1 I I I
SERVICE/MOP SINK • 1 I I I 11 I I I
TOILET I I I I I 1 • I 1 I
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WASHING MACHIICCONNECTION I I I I I I I I I
WATER HEAT- ALLTIPES I I I I I I I I
WATER PIPING I I I I I
OTHER / v wt4 -e. I I I I I I I I I F
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INSURANCE COVERAGE:
I have a current[lability Insurance polity or its substantial equtvalentwhich,meets the requlremerrs of MGL Ch.142. Yes -No 0
W YOU CHECKED YES,PLEASE INDICATETHE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY$ OTHERTYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAVER I am aware that the licensee does not have the insurance coverage required by Chapter 142 of th
Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE BOX ONLY: OWNER 0 AGENT 0
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered) regarding this application a - .. - and accurate to t
best of my Knowledge and that all plumbing work and installations performed under the permit is fo this app i -:on will be
compliance with all Pertine
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provision of the Massachusetts State Plumbing Code and Chap - 142 of. e - Laws.
PLUMBERNAME nt ct WA-12C--R” SIGNATURE i % Or
LIC# t 76 0? MP❑ JP CORPORAION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME tr11 IC& UJ Ct 7' P t f (4t7 ADDRESS /9/ 414 4 S
CITY Wei` 664 ems-62,IS STATE ntec(ZIP 026 Act EMAIL
TEL $013 77a) l 5Y?2) CELL FAX
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ROUGH PLUMBING INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ON V
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FEE: S--- PERMIT II__----_
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