HomeMy WebLinkAboutBLDP-20-002381 p'x
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
MA DATE /'G Z/— l I PERMIT#L?LP�
JOBSITEADDRESSS 4P 2/2 2
ee.p.0v ��'' OWNER'S NAME
POWNER ADDRESS 2/2 2. oilee o e✓ TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:O. RENOVATION: PLACEMENT:❑ PLANS SUBMITTED: YES❑ NO 0
FIXTURES 1 FLOOR-' BSM 1 2 3 4 5 J 6 J 7 8 9 [ 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND 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
I TOILET
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. YE ' NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POUCY 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 apVfication waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
14.1 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.
PLUMBER'S NAME LICENSE#`2o7y NA
MP❑ JP CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME ,?r cr.? 4 7 v—P ADDRESS 2 !- 12 G5/3.e e7' 4 v-e
CITY G&'.. ).-4?' h7 4 STATE /4)10 ZIP 0 a G? 3 TEL ,._Pee- 1`22- OC°c
FAX 4 ' -' CELL cS� e- i e6 EMAIL
r�. 4
n,rr_ROUGH PLUM INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
B==
Yes No /
THIS APPLICATION SERVES AS THE PERMIT 0 ❑ ���%� c
aWl & FEE: $
PERMIT# �/ bT • /7/ 9
(� PLAN REVIEW NOTES •
•
•
•
' I I
I
1