HomeMy WebLinkAboutBLDP-16-002867 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
1'"- 4 CITY /Pl>ZD6/,/ MA DATE // PERMIT# a- -4-eta7bJ
JOBSI E ADDRESS '�-!//�//L/ I OWNER'S NAME /V/c K A_darrv6
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE OMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:j PLANS SUBMITTED: YES❑ NO 0
FIXTURES 1 FLOOR-0 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
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES f
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 a NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW Mai '
LIABILITY INSURANCE POUCY ] OTHER TYPE OF INDEMNITY 0 BOND ❑ ,m 3
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required bythaptery 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER El 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 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. .�%lam(
PLUMBER'S NAME LICENSE# /h vat/ SIGIF ARE
MP af JP 0 CORPORATION 1/r# f23I PARTNERSHIP❑.# LLC❑#
COMPANY NAME fi///' 4 #/T'e ADDRESS //ZdiyP 37—
CITY /,,e,r/4,OG / STATE /t4 ZIP D U‘73 TEL
FAX CELL 71448I -4'2 Pr/ EMAIL
Cam`-`J
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES