HomeMy WebLinkAboutBldp-20-000047 •
s MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
--'%�_ CITY Ci't/ y g4 f2 wft MA DATE 7/a/i9 PERMIT# 1/ f 7O d V
JOBSITE ADDRESS 15' A' -f Q 0st e R AOWNER'S NAME F (y A4)
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ❑ RESIDENTIAL,
PRINT
CLEARLY NEW: ❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES-1 FLOOR BSIv1 1 2 3 4 5 6 7 B 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 T
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN I
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY j 7 i i 7 j
ROOF DRAIN 1
SHOWER STALL •
SERVICE I MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER S -ri c (Z d}t Se I
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY pT.. OTHER TYPE OF INDEMNITY ❑ BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
I` Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
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 compliance with all Pertin o ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C-
PLUMBER'S NAME 00 LICENSE# /p 3,9 z. TURE
MP 171 JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME • C H A-C A J ADDRESS /3? B !r f*fA) S
CITY r ?A✓ STATE M itcli- ZIP Oa 6lly / ` TEL 5-0� •a�'Y- ' 3 C I
FAX CELL EMAIL S-b m 4c/�02(7 &m p 01 . er."
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT it
PLAN REVIEW NOTES PZ-
Z /e7.:1 7/5/1?