HomeMy WebLinkAboutBLDP-16-000374 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO PERFORM PLUMBING WORK
CITY jG(` Q(J71 / Fd . PERMIT# I o-/6--oct/ 7r
MA DAT
JOBSITE ADDRESS/Q� / i //l G' E /G
OWNERS NAM
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL El/
PRINT
CLEARLY NEW:❑ RENOVATION: / REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO-Er
FIXTURES Z 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/OIL/SAND 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
OTHER
Peg-&e-rtem1 /M-eltr e0
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YE NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ 7 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
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 corn liance ' Pertinent
provision of the
Massachusetts State Plum ingin/Code and CChha t 1424 of the General Laws.
PLUM R'S NAME �v� E / Z6 5 LICENSE# gP d SIGNATURE
MP- JP❑ CORPORA ION # PARTNERSHIP
COMPANY NAME('/Yi[ ' it/(, / O -4�. 6 ADDRESS/ 0 ✓ L�LYi �i/�
CITY(// �" 174 STAT ZIP / TEL TEL r3
FAX CELL ,7 , 7/5 EMAIL Ll1
'/A137
elf
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
fr 4 /I> Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
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