HomeMy WebLinkAboutBLDP-15-001564 '� MASSACHUSEi fS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK is�1�
• az cm' MA �DATE 1.r �`_ PERMIT#nP"/S efla
JOBSIiEADDRESS (0?Ct Mk* OWNERSNWmE SA*nCRND£ 4 -
pOWNER ADDRESS 5 henC TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL' EDUCATIONAL 0 RESIDE IAL 0
PRINT
CLEARLY NEW:0 P.B4OVAT ION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
FIXTURES 2 FLOOR-. BSMT 11 I 2 3 4 I 5 6 7 B 9 10 11 12 1 13 14
BATHTUB �
CROSS CONNECTION DEVICE I a
DEDICATED SPECIAL WASTE SYS
DEDICA i tD GAS/OIL/SAND SYS I
DEDICATED GREASE SYS I
DEDICATD GRAY WATER SYS I
DEDICATED WATER RECYCLE SYS I
DRINKING FOUNTAIN I
DISHWASHER I
FOOD DISPOSER
FLOOR/AREA DRAIN I
INTERCEPTOR(INTERIOR)
KITCHEN SINK I I
LAVATORY
ROOF DRAIN-- I I I
SHOWER STALL I I I
SERVICE/MOP SINK • I I I I
TOILET
URINAL � 1
WASHING MACHINE CONNECTION
WATER HEATER ALLTYPES I I I I I l
WATER PIPING
OTHER I I
I I I I I
I I I I I I I I
i I I I I I I I I
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent which,meats the requiremerts of MGL Ch.142. YestNo 0
IF YOU CHECKED YES,PLEASE INDICATETHE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER rips OF INDEMNITY 0 BOND ❑
OWNERS INSURANCE WAIVER: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 ❑ •
Signature of Owner or Owners Agent
I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to t
best of my Knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be
compliance with ally Pertinent provision of the Massachusetts State Plumbing Code and Chr 142 of the Laws.
PLUMBER NA//ME IAC �.J M - E Vi preKF re.n..) SIGNATURE
UC# r!a F I7 b2 MPO❑ CORPORATION 0 PARTNERSHIP D# LLC Of
COMPANY NAME T9" PCrUYl4t3ADDRESS S70 -F.ms F-F t-sr S t'
CITY dos rrdil STATE til ZPoa I21 EMAIL' Kc--ox.„0.2 z-F S,0Y,cdvel
m ,/i) 6? -00ea CELL 7V( `fQY- ?-x'16 FAxCtia61-oca7
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ROUGTT PLUMBING INSPECTION NOTES THUS PAGE FOR INSPECTOR USE ONLY
1 INAL TNSPI;CTTON NOTES
. Yes Na
_ CA 0iS- VES •S1C - I 0 ❑ -
FEE: $--- PERMIT it-----
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PLA 11% I6 a i OTES
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