HomeMy WebLinkAboutBLDP-16-002300 N
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBINI RK
CITY tiaYrw-1[. MA DATE /0 7 v"( f PERMIT#I P/6'610 16/0
JOBSITE ADDRESS F IC �L C
°v fi- OWNER'S NAME
POWNER ADDRESS (3.2 " Ahe 4/ TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ! RESIDENTIAL 0
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:❑` PLANS SUBMITTED: YES 0 NO 0
FIXTURES 7 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
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
LIABIUTY INSURANCE POLICY ❑ OTHER TYPE OF INDEMNITY ❑ BOND ❑
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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 s rilitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed u the permit issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 the General Laws.
PLUMBER'S NAME M -t_ a' BR . LICENSE# irz ra SIGNATURE
MP JP 0 l CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME 1`1 0/ P+ ADDRESS P U, /If P 7--
CITY • �enes/,v STATE M4- ZIP d Z(v TEL -
FAX FAX / CELL SD e, 3" 99/4' EMAIL
'Cu 071
4/ /191 coi f
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ROUGYk PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES `,
Yes No 1
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ �'
FEE: $ PERMIT#
PLAN REVIEW NOTES
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