HomeMy WebLinkAboutBLDP-15-003997 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY 5O V T� t,I4 YTT / .3 ed/J/
1 MA HATE � PERMIT#��/�15--00
JOBSITE ADDRESS SS eGCA^( S• y OWNER'S NAME /psi yi nz mien,
OWNER ADDRESS TEL 779-3 92 -OSV. AX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[I)/
PRINT
CLEARLY NEW:2/ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑L'
FIXTURES 1 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
WfkSHING MACHINE"CONNECTIONI
WATER HEATER ALL TYPES
WATER Pk/9q 5i _
OTHER AN 0 2015 —
0/// INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES'NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [( OTHER TYPE OF INDEMNITY ❑ 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 application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this applicatiserfft true an cur to s o y I�gowl _edge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance t Pe in t provi �(of
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Massachusetts State Plumbing Guile/it'd Chapter 142 of theGeneral Laws. /
PLUMBER'S NAME b/W G/ T / + J LICENSE# /0 37 7 SIGNATURE
MP V JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME SS Ak ADDRESS 3 6 t050"14la^/ fr
CITY tijeST OfolevrifiSTATE Ai' ZIP 2h7.3 TEL Stie . 7Y
FAX CELL (50 r-fl7-VY yEMAIL
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
o0/ Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES