HomeMy WebLinkAboutBLDG-15-006423 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
5� CITY if jyf t,t/ A D H MA DATE ///o .PERMIT#"0P^/5---419 4gal
JOBSITE ADDRESS �� [�'���i!/f�J/ /` t. OWNER'S NAME/O Y/ e vV4-77
OWNER ADDRESS (fcgG!f -e TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL gcr
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:14 PLANS SUBMITTED: YES❑ NO
FIXTURES 7 FLOOR— 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
WATER PIPING r
OTHER
INSURANCE COVERAGE: )~
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch142 S NO ICI
JIIN 6 201
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW'
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND -
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OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the cf/ '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 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accu ate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in m nce ' I Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME/"e�"(�/"Xer„,//,ci LICENSE#4P/77 SIGNATURE
MP❑ JPS' CORPORATION❑# PARTNERS P❑# LLC U#
COMPANY NAME ADDRESS 7 $721/�/e / e z;1 /
Al �[ ,e G / I EL 0 7� �"�Z�
CITY ��/'J/ld�//� STATE %��.f ZIP G a�,//� � 1j �� � //�J
FAX CELL EMAIL
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