HomeMy WebLinkAboutBLDP-15-003599 ///i//-(//(/ti%�
c) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY fn-d�' ` MA DATE Ii�DI PERMIT# 3LD�-/5-co
L O - / )1 6 P )✓Dlt 2 Yl OWNER'S NAME ).Y1)ft. I&Mfr)
JOBSITE ADDRESS c�— (,�rh S
PD
OWNER ADDRESS TEL FAX
TYPE OR `-�OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL El RESIDENTIAL
PRINT S
CLEARLY NIEW:❑ RENOVATION:❑ REPLACEMENT:[1-eK.- PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR—I 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 1
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY 1 1
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET ( 1
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
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 TH PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND El
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 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 complian with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER'S NAME ('y L StR,ta,�r�/ LICENSE# 77
SIGNATURE
MP[V JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME Sa_y--e Alec dt4 ( ADDRESS e26.2 6;a s I-
CITY / " 1/! l 5 STATE/V, ZIP O Pt TEL
FAX CELL S D br - "09`2_ EMAIL ,--e r(c- Set 44 &- 47.er
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
0;yf- JDLIp I/6//<- Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
4