HomeMy WebLinkAboutbldp-20-001896 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
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.i - Z CITY 41" MA DATE `O L 7A PERMIT##-/P""'-001 D !0,
� JOBSITE ADDRESS `ii4in br OWNER'S NAME r^-Lti •134
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL GV
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:er PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR-f BSIv1 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 1
1 i DRINKING FOUNTAIN
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FOOD DISPOSER _
FLOOR I AREA DRAIN l 10 7
INTERCEPTOR(INTERIOR) ,
KITCHEN SINK
LAVATORY
ROOF DRAIN I I I 11
SHOWER STALL
SERVICE/MOP SINK ""
LI
TOILET
M um 't-T I .1
URINAL _
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES i
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®rTI0 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY EV OTHER TYPE OF INDEMNITY 0 BOND 0
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 ❑
r
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 i pliance with all P rtrovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. IA-
PLUMBER'S NAME LICENSE# ' 'l yt‘ tS'$s& SIGNATURE
MP Tr-
5 JP El CORPORATION 24 3t/O t PARTNERSHIP❑O LLC❑#
COMPANY NAME "--( ' fghi ADDRESS (D 3 4'L6 6 eL D
CITY 444/5 -- STATE AM' ZIP 0 2-40 a TEL
FAX t--6C1 " 0 iG, `pZ 9/7 CELL 51)o ill Ss f} f4S- EMAIL It^44- j Co"-Iv e `pi-0-0 Goy".
SCE — Gt--u /S73
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT# //P71—
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PLAN REVIEW NOTES
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