HomeMy WebLinkAboutBLDP-23-11952 crr w 15 ul t n(A/c
MAS ACCHUSETTSA�UNIFORRM APPLICATION FOR A PE IT TO PERFORM PLUMBING WORK
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CITY yll` DU Ll/IFtY MA DATE
L l R{M`R#�Q�`pll�/z 5j �!1/1 5 Z
JOBSITE ADDRESS ( /�C Z OWNER'S NAME /�1.`i!I t�N ICl/(l—
P OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED:YES 1:1---IV6❑
FIXTURES 1 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 GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM17.
DEDICATED(0Fk'WATER SYSTEM ) 6
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER •
DRINKING FOUNTAIN _
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN R E - V
SHOWER STALL _ _
SERVICE!MOP SINK gQ(
TOILET � ?02
URINALAJI_
WASHING MACHINE CONNECTION `ui N"
WATER HEATER ALL TYPES
WATER PIPING i1
OTHER v-r� ((� -
I
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 COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY OTHER TYPE OF INDEMNITY❑ BOND❑
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 0
SIGNATURE OF OWNER OR AGENT
LU I hereby certify that all of the details and information I have submitted or entered regarding this application am true and a rate 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 II Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NA D. Al/Q3lj 5 LICENSE# SIGNATURE
MP JP CORPORATION❑# PARTNERSH ❑.# q ,LLC❑#
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COMPANY NAME /70 6�T -7 / ,z-I// ADDRESS 25 41t) 7 A/O j,/ V
CITY V M 01/711 STATE ZIP 026 7 TE5 U-50 0 9 �j
FAX CELL EMAII ' I ot/ c
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