HomeMy WebLinkAboutBLDP-20-000531 YgOlr
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY 1. �K' �Oti\ MA DATE \ \ ` \ PERMIT#/%/-4 /' '0
JOBSITE ADDRESS 1 h'W�Nl1^c�04 OWNERS NAME 4u�C 4 -�--
POWNER ADDRESS �\ � �C FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTI
PRINT
CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMEN PLANS SUBMITTED: YES❑ NO❑
•
FIXTURES Z 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
DISHWASHER ,, •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY \ \ \
ROOF DRAIN
SHOWER STALL _
SERVICE/MOP SINK
TOILET \ a
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
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 NO 0
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCI 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 ' ation are true and acc to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application ' compliance w h Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
NK-
PLUMBER'S NAME LICENSE# ���� � SIGNATURE
7. JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC #
COMPANY NAME�C - -- i \ � ADDRESS ( Nf\t) N
CITY ceiv\ -, � STATE ZIP TEL
FAX CELL \ 3c5 1J \ EMAIL'C'�-C--4-11-) N10\�
1
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
/P6� cpe THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
/ / FEE: $ PERMIT# f c /
PLAN REVIEW NOTES ( 1°/67. / f