HomeMy WebLinkAboutBLDP-20-002964 MASSACHUSETTS UNIFORM APPUCATION FOR A ERMIT TO PERFORM PLUMBING WORK
�_I_ CITY O MA DATE ( PERMIT# L r- l .( of?
JOBSITE ADDRESS 3 9 scp,i_frzyu, 1,47 OWNER'S^ NAME /�-C'4 )L ?
POWNER ADDRESS t:S- L �OC� G 5—Z r FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL ElED ATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:0. RENOVATION:0 REPLACEMENT:wi PVC . PLANS SUBMITTED: YES El NO
FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 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 J
DISHWASHER -
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DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
j LAVATORY
I ROOF DRAIN
` SHOWER STALL / t
SERVICE/MOP SINK pi t
..4, c'i
I TOILET I
URINAL { L I
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES `' (7:7 ,
WATER PIPING -
i
OTHER Q_ , ) C��—D (� / i y
1 INSURANCE
N URANCE COVERAGE:
i I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ] NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY [g OTHER TYPE OF INDEMNITY 0 BOND 0
I 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 ap?Gcation waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
141 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 al 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# I/C(/
2 / � SIGNATURE°`
MP❑ JP[VI CORP RATION 0# PARTNERSHIP /# LLC❑# P P
COMPANY NAME " I 1-' l� ADDRESSC:7 V 57 1 C 6 c I V
CITY STATE'V"4 ZIP 6 ? (,) 73 TEL 7l Y6aZ
FAX CELL
EMAIL L4\!)-
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ I= �rz�� ��Ce ��.
FEE: $
PERMIT# /7/7 •
PLAN REVIEW NOTES
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