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HomeMy WebLinkAboutBldp-20-000152 ' ;9i /trfl T a0 � '. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK niiri j 4 -1� 4 CITY Y`i'ci 4r7 0 Gl ii/ MA DATE i © l PERMIT#. +DP 'OW �� JOBSITE ADDRESS el MI OWNER'S NAME 14/1J-eV (4II C,9 POWNER ADDRESS 5'Z2 TEL 6/1 c !/'A9rf FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL(2' PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT:( ' PLANS SUBMITTED: YES❑ NO FIXTURES 7. FLOOR—+ 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 r'---= _ DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER _ FLOOR/AREA DRAIN - INTERCEPTOR(INTERIOR) l KITCHEN SINK LAVATORY [,.., ROOF DRAIN SHOWER STALL SERVICE/MOP SINK � - 14/ TOILET �. .r '� .`>—,- URINAL j WASHING MACHINE CONNECTION " f U� 1 [�],Q �` • 1 WATER HEATER ALL TYPES BUILDING, yrA E NT WATER PIPING By : OTHER i i INSURANCE COVERAGE: { I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES.Z NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i 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. r 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 compliant with all Pertinent provision of the Massachusetts State Plumbing Code and yp`t/err 142 of the General Laws. X (/, a m ip PLUMBER'S NAME rg 1 t el4 t$ LICENSE# 1/ 1l '? SIGNATURE MP Vf JP❑ .... , CORPORATION❑# PARTNERSHIP❑.# LLC e# ��/ COMPANY NAME 6'/ 4 /111 AY./4 L 61 ADDRESS/17( Xt2 4f//Ih/ f%"'�/ CITY i STATE,* ZIPS/./ i/i/ C 01 7 TELc°8' 62/g:" 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 L e • Y. a,