HomeMy WebLinkAboutBLDP-15-003600>~ � NIASSACHUSETITS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
5 1 CITY W y G ('M r•)!i �'v '"MA. DATE 14` �'PERMIT# UP-I J6"-c66 66
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JOBSITE ADDRESS ( Z 1 - G , OWNERS NAME ✓�"
OWNER ADDRESS A.0 TEL FAX
TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDB'IT IAL
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO ❑
FIXTURES FLOOR-' I BSMT 11 I 2 I 3 I 4 I 5 I 3 I 7 I B 9 I 10 I 11 I 12 I 13 I 14
BATHTUB I I I I I I I I I I I
CROSS CONNECTION DEVICE I I
DEDICATED SPECIAL WASTE SYS I I I
DEDICATED GAS/OIL/SAND SYS I I I
DEDICATED ED GREASE SYS I I
DEDICATD GRAY WATER SYS I
DEDICATED WATER RECYCLE SYS I I I
DRINKING FOUNTAIN I I I
DISHWASHER I I I I I I I I I I
FOOD DISPOSER I I I I I I I I I I I I I
FLOOR/AREA DRAIN I I I I I I I I I ( I I I
INitHC l iUR(INTERIOR) I I I I I I I I I I I I I
KITCHEN SINK
LAVATORY I I I I I I I I •I I I I I
I ROOF DRAIN-
SHOWER STALL I I I I I I I I I I I I I
SERVICE J MOP SINK I I I I I I I I I I I I
TOIL. I I I I i I I I I I I I I
URINAL I I I I I I I I I I I I I
I I I I I I I I I I I
A
i I I I I I I I I I I I ,
Aur 21I I I I I I I I i I I I I
I i I I I
INSURANCE COVERAGE:BU_LD..NG D;V,rJ MEN
Ithave a curre , '+ -
e policy or its substantial equivalent which,meets the requirements of MGL Ch.142. Yes 0 No 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE SY 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 tF
Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE BOX.ONLY: OWNER ❑ AGENT ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information l have submitted (or entered) regarding this application are true and accurate to t
best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be
compliance with all Perfinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER NAME !T) /V C r f rfiQ SIGNATURE
LIC# N`Zr/ MP Q JP❑ CORPORATION ❑# PARTNERSHIP ❑# LLC ❑#
COMPANY NAME /44 CI; r ADDRESS O (�/ � 6C/I C I (� �C J r/t/f
CITY ( '"c f (v7�)t/I .�STATE l P/7)2,66 EMAIL. ✓
cal_ 47) 7 T7O cJ/ Z 2 FAX
ROUGH PLUMBING INSPECTION NOTES TIITS VAMP FOR INSPECTOR USE ONLY
FINAL TN I'>;CTION NOT1;S
• Yes No
THIS APPLICATION SERVES AS TFIC PERMIT ❑
FEE: $ PERMIT II
nr �rr nr'yIU'W NOI'L;S
•
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