HomeMy WebLinkAboutBldp-19-004044 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY Vci ov firt MA DATE PERMIT#wP17--009079
JOBSITE ADDRESS f1/ 6cdf)e Bc'e4 ►? - OWNER'S NAME 5/PAC L's
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES T 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
FLOOR!AREA DRAIN
INTERCEPTOR(INTERIOR)
_ KITCHEN SINK
I LAVATORY Z
ROOF DRAIN E I V
SHOWER STALL — -- •-
SERVICE/MOP SINK t
TOILET I tLAN
Li1.t j j1
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES ,r, p i i�r r t _
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TY OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ 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
!Li 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 co fiance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `
PLUMBER'S NAME IMkn.`k-C. LICENSE# f hOCfl . SIGNATURE
MP 53 JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME plA K v44 t l I eci ADDRESS PC &X `1 2 s—
un, STA M ZIP TEL TEL SOS( 2-k, 7 37S j
CELL EMAIL
FAX
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elf
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
j ' /L_ / c ' 7C THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ fi/-`&
P/r
/./ ! / FEE: $ PERMIT#
PLAN REVIEW NOTES �j