HomeMy WebLinkAboutBLDP-15-001664 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
-s i CITY /a/'F' o..Cit MA DATE JD' 7— / Z/ PERMIT#/r'DP-K-00q
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JOBSITE ADDRESS IS 1 h .x,.61 P 13Q//y L''1 OWNER'S NAME ,W ER)SS /r O,•
P \OWNER ADDRESS TEL FAX
TYPE OR 0 CUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL Er.°
PRINT
CLEARLY NEW: RENOVATION:1 REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7 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 GASIOIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN -
INTERCEPTOR(INTERIOR) •
KITCHEN SINK
LAVATORY J
ROOF DRAIN
SHOWER STALL •
SERVICE I MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
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. YEeNO 0
IF YOU CHECKED YES,PLEASE INDICATE THE E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POUCY 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 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 - and ac tett- . .- best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be In pliance%'y�4lV- ne • ovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
'
PLUMBER' NAME LICENSE#/.3 / SIGNATURE
MP
PLUMBER'
❑ ., CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME Deg-1/4-J c_ Y9Xr+n 6,.'etc- ADDRESS L .7/ d✓y
CITY C0e,141 STATE/7 A. ZIP 6:W1C CO fEl E CE 111
FAX CELL 4 Yb 2 7 E1 EMAIL // 2011{
OCT O /
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BUILDING DEPt.' /O(!/j"
L� uY.
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
ft# 1' 10 arc 4-041 /6/f/r Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES