HomeMy WebLinkAboutBLDP-15-003824 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
l'-.% CITY 1X,Lrrr7c7t.7-1'e,:por-A- MA DATE 1171'-J/15- -1 PERMIT# /-I),P l S=GO ,' �;/
JOBSITE ADDRESS <G P{)QctsOr-+CoQc �i r 1 . OWNER'S NAME , Qor IYk ry �` rl
POWNER ADDRESS TEL - -,=)C.J1 FAX
TYPE OR , OCCUPANCY TYPE COMMERCIAL! = EDUCATIONAL 11 RESIDENTIAL PIP
PRINT
CLEARLY NEW: n RENOVATION:Li REPLACEMENT:2' PLANS SUBMITTED: YES L N0 fl
FIXTURES 1 FLOOR-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB -- -
.�—]'
CROSS CONNECTION DEVICE ' _ ., 1 - I I,
DEDICATED SPECIAL WASTE SYSTEM J _ i
DEDICATED GAS/OIUSAND SYSTEM 1
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM I _ l 1 h
DEDICATED WATER RECYCLE SYSTEM ti 1
DISHWASHER J g
DRINKING FOUNTAIN -, i '__ _ 1 J �f 1 - ,
FOOD DISPOSER -
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) `
KITCHEN SINK _ .. —3 r
LAVATORY
ROOF DRAIN I y ,r I .* IN y ;.,
SHOWER STALL s
SERVICE/MOP SINK
TOILET -
v I w s 01
URINAL Ae„ 4 „,
WASHING MACHINE CONNECTION _ ' T Jai l , ..
� '
WATER HEATER ALL TYPES or , . i
WATER PIPING
OTHER: F.._- - t 4 .4 ,,„ ,, ,t, _ _
I !_ L . 1 i_ 1 I 1 .
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of biGt.Ch.142. YES 1 I NO [_]
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY L] OTHER TYPE OF INDEMNITY Li BOND Pi
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 El AGENT El
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 a rate est my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in corn ' nce wi ertinent p vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. .
PLUMBER'S NAME ` A tn-1t S 4->A 2/a i S LICENSE# 1 03' '1 "(". SI ATURE
MP[1 JP[1 CORPORATION❑4 PARTNERSHIP-# LLC r
COMPANY NAME ADDRESS
CITY STATE ZIP TEL
FAX CELL I EMAIL
y/Y
` T
ROI.IGH PLUMI}ING INSPECTION NOES BELOW FOR OFFICE USE,ONLY FINAL INSPECTION NOTES
Yes No
TI1S APPLICATroN SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTIS
;40