HomeMy WebLinkAboutBLDP-23-8506 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUM
BI WORK
-L ,` CITY GU MA DATE '�f f PERMIT#(SLOP-23-gS6G
JOBSITE ADDRESS 5 - V OWNERS NAME 577' 7'-(f�L,
P OWNER ADDRESS 3/fr/lit TEL FAX
TYPE OR OCCUPANCY COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION:0 REPLACEMEN PLANS SUBMITTED:YES 0 NO❑
FIXTURES 2 FLOOR-. BSM 1 2 3 4 5 6 7 B' 9 10 11 12 13 14
BATHTUB --
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOIUSAND SYSTEM
DEDICATED GREASE SYSTEM _
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM ,
DISHWASHER _
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR) _ -
KITCHEN SINK _
LAVATORY
_
j ROOF DRAIN
I SHOWER STALL -
SERVICE I MOP SINK _
I 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 0
IF YOU CHECKED YES,PLEASE INDICATE THE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
1 Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
41 I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accur e to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be In compliance with ertinent provision of the
Massachusetts State Plu ng Code and Chapter 142 of the General Laws. �
PLUMBER'S E (�V t 7 LICENSE#/�j�1/yn,4 SIGNATURE
MP JP �Q CORPORATION❑# PARTNERSHIP 0# LLC❑#
COMPANY N/ 1ff (t
}/� ,7 /�� ADDRESS Q 2 /�
CITY STATE/t f ZIP 2 J, TEL ----/yyyjjj ,/ Q J�J✓
3
FAX CELL EMAIL (4 [/Gr.�/C al`dv �/�_J
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