HomeMy WebLinkAboutBLDP-23-11857 •
MASSACHUSETTS1 UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
UYTa CITY
GeYJYtrrL MA DATE 'I," l3^a Z PERMIT#BLOP 23-IIPS7
JOBSITE ADDRESS ?3 VY.A�v) 4' OWNER'S NAME C.-VNr c, r Cyr ,
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL IZI,.."--- EDUCATIONAL 0 RESIDENTIAL 0
PRINT ^/
CLEARLY NEW:0 RENOVATION:l REPLACEMENT:0 PLANS SUBMITTED:YES 0 NO❑
FIXTURES? 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/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 I
ROOF DRAIN
SHOWER STALL _
SERVICE I MOP SINK I
I TOILET
URINAL _ _ _
WASHING MACHINE CONNECTION _ _
WATER HEATER ALL TYPES y
WATER PIPING 1
OTHER _ _
INSURANCE COVERAGE: 1
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES t i- NO 0
IF YOU CHECKED YES,PI EASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POUCY II/ 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
III 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 J
'^ with all nent provision of the
Massachusetts State Plumbing
Code and Chapter 142 of the General Laws.
PLUMBERS NAME'�( 1-y,.w,4 �r1-J') LICENSE# (/a$3 SIGNATURE
MP E 1P 0 (� CORPORATION 0# PARTNERSHIP❑.# LLC❑#
COMPANY NAME �641/z5 r 4.t I7 ADDRESS q., ell rn iri p�`
CITY F. k)t \kl t7 STATE fA ZIP atI4J�t5 TEL 7eg' d 3 7.A 13G
FAX CELL EMAIL 1 t t �CL`c5 r .,r-t 1.-
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