HomeMy WebLinkAboutBldp-20-002225 y 01 0-7
MASSACHUSETTS UNIFORM APPLJCATION FOR A PERMIT TO PERFORM PLUMBING WORK
�— PER IT# -02D-oo.az1�
)_,_ CITY /�j �/m 6� MA DATE �� /� /
JOBSITE ADDRESS OWNER'S NAM
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL[;
PRINT
CLEARLY NEW:D. RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMf I ED: YES❑ NO❑
FIXTURES 1 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/OILISAND SYSTEM v
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
ROOF DRAIN
SHOWER STALL 1-4 - 9(1/o '(Of4
SERVICE/MOP SINK 1)t 1
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTH
Z+7;A:
f F
• 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 E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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: 0 NER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
1 t I hereby certify that all of the details and information I have submitted or entered regarding this application are true and ac to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in corn fiance wi Pertine rovision o the
Massachusetts State Plumbing Code a d Cha r 142 of the neral Laws.
PLUMBER'S NAME ��� r LICENSE# 007. SI NATURE
MP❑ JP CORPORATIO ❑# PAR ERSHIP❑.# LLC 0#
COMPANY NAMEADDRESS6
/ 1;24v
CITY /Qrle51 /,,_Ct
STATE //1? ZIP TEL
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 •M`i/ Q
I _