HomeMy WebLinkAboutBLDP-23-10680 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
• CITY JC Ycir(t1d,tb \ MA DATE 3 —I5 PERMIT# 3
JOBSITE ADDRESS 7 Cl 5h 1?- 7tV� OWNER'S NAME J K«Lv K. 13 e--rt r
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCI EDUCATIONAL❑ RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO 0
FIXTURES? FLOOR-i 1SM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB A _
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM —�
DEDICATED GAS/OIUSAND 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 v
WATER HEATER ALL TYPES
WATER PIPING --- HAy 1 4 2
OTHER F
�yGILD Nr rbyH Rl MENI
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 1:1-40❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY -OTHER TYPE OF INDEMNITY ❑ BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massa setts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGN OF OWNER OR AGENT
Li I 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' compt a with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME C IA.r i-} d; � LICENSE# GNATURE
MP❑ JP I�-.„ CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME ,IjJcre 4 C_ ADDRESS S/ i
l /asps
CITY / yG wI r STATE h// x ZIP n"` 0 TEL
FAX CELL ll L 3(k,UI(p f EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES