HomeMy WebLinkAboutBLDP-20-001756 6g,7UcK1 r
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
-=1 CITY ;<t. ( i ( ' rj ;4"" \ MA DATE CI i 3 0/1 C PERMIT# I P 01O_06 rig,
�� JOBSITE ADDRESS I (2) 1 i (-- b nt Qs t2 OWNER'S NAME . 0u-I .7C VI'd(Ilf6c\.i
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL IJ
PRINT
CLEARLY NEW:❑ RENOVATION:.❑ REPLACEMENT:V 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 _
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER 1
DRINKING FOUNTAIN
FOOD DISPOSER _
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR) _ u MCI-
KITCHEN SINK _ ) 3
I LAVATORY 1 • ,
ROOF DRAIN
SHOWER STALL 1,
SERVICE/MOP SINK
TOILET
URINAL _ _
WASHING MACHINE CONNECTION
i 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 L NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY 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.
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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 accurate best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in plia with all nt provis• of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �(
PLUMBERS NAME C \ ,rLs 1.,\\h 'ti NC )c ,LICENSE# D`t 'c a SIGNATURE
MP 0 JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME C.-\ cAks I. C.i,c cJa 14 ADDRESS 1-1 4 1 Yid'.
CITY 6 9Gt rr7 of STATE ZIP ( Cs G2 / TEL V L3� i 9
FAX CELL EMAIL
C1C-1 - 0� 44�ID off
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
?()/ 2 FEE: $ PERMIT t# riA4/Pfl
-/,`� 70 /% PLAN REVIEW NOTES
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