HomeMy WebLinkAboutBldp-19-006989 _ Cd/l/r 0.- 1/
• MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
. 1 a CITY y?Y oV MA DATE 6 /0 1 1 PERMIT# D[e�/9'Gt96
JOB SITE ADDRESS 7 •�,qn i„c roOl)C OWNER'S NAME rpi e-y
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[.,
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES E NO V
FIXTURES Z FLOOR--+ BSIvI 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
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DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
E DRINKING FOUNTAIN _
J FOOD DISPOSER
FLOOR I AREA DRAIN
— INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY - .
4 ROOF DRAIN
ei SHOWER STALL _
SERVICE/MOP SINK
i TOILET
URINAL
WASHING MACHINE CONNECTION
jWATER HEATER ALL TYPES
WATER PIPING _
„' OTHER
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INSURANCE COVERAGE:
8 I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO 0
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IF YOU CHECKED YES,PLEASE INDICATE TH TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
---1 LIABILITY INSURANCE POLICY [� 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
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 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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 0.
PLUMBER'S NAME LICENSE#al g 1. SIGNATURE
MP V JP❑ CORPORATION❑# PARTNERSHIP 0.# LLC R4
COMPANY NAME :s.1.4.1 0cc.,nnf PI,,, A/-/,Le ADDRESS 10 G rcc�4 pl-erSIA R()
CITY G enttfil:I IC STATE IAA ZIP drl- CS 2- TEL /
FAX CELL7 741 3 5-3 g 301- EMAIL
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT It
PLAN REVIEW NOTES /✓AJ?
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