HomeMy WebLinkAboutBLDP-15-003290 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY Lies yAr„NO.aln MA DATE laIfD( !if PERMIT# P-yr--ctfi
JOBSITEADDRESS ,rho SPr;nodi? t/M? OWNER'S NAMEPD$'iVnainitnii?
OWNER ADDRESS ___Les tie Roscn6141-1 TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL kr
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:21 PLANS SUBMITTED: YES 0 NO 0
FIXTURES I 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 1
FLOOR/AREA
AREA DRAIN ��/J
INTERCEPTOR(INTERIOR) ryry
KITCHEN SINK /
LAVATORY eQ
ROOF DRAIN _ •
SHOWER STALL
SERVICE I MOP SINK ` 0W��
TOILET a
URINAL fY I •
• WASHING MACHINE CONNECTION 1 � -
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WATERHEATERALLTYPES •
WATER PIPING
OTHER / -
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES JO NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITYINSURANCE POLICY L4 OTHER TYPE OF INDEMNITY 0 BOND ❑
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 ❑
SIGNATURE OF OWNER OR AGENT
hereby certify that allof 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 complian�with all rtinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �
PLUMBER'S NAME Fail F'r j 2 serf.% IP LICENSE# /09/2 SIGNATURE
MP Ni JP 0 CORPORATION 0# PARTNERSHIP 0# LLC❑#
COMPANY NAME net 12 -9toss- P. 1 'P ADDRESS 3w Pr/re S1
CITY CeiZter,.'1e STATE MP ZIP oa03a- TEL 5872 .-7P33
FAX CELL EMAIL
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