HomeMy WebLinkAboutBLDP-18-004159 s� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
( CITY Y/�i�rn n�, f` f T' MA DATE 49-3/I? 112
PERMIT#/al�P/7'eOy/4J
JOBSITE ADDRESS itiva25- u_iie'4/ / 0_1/449Fth1.145e//AWNER'S NAME
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT �/
CLEARLY NEW:❑ RENOVATION: Lh" REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES-1 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 J
I LAVATORY 4� -" �+
ROOF DRAIN R C I E
SHOWER STALL F L •
SERVICE/MOP SINK
TOILET
/°-06
I URINAL
WASHING MACHINE CONNECTION e PA TMENT
WATER HEATER ALL TYPES �Y—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
LIABILITY INSURANCE POLICY V 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 ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application re 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 i compliance wit II Perti ent pro ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME LICENSE# /0t`53(. SIGNATURE
MP (• JP❑ CORPORATION❑# PARTNERS 0# LLC❑#
COMPANY NAME - LZ'( di 4 Sr/r+� 1L„ �F- r i G: ADDRESS -L?oK '8j i
CITY 3 , (�'/2(�1�K� STATE t/ -CS ZIP C9 TEL( ) c cji - 0 -7/
FAX CELt(77y)79- -- s a6 EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
Oti �� aA-C- THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
// laio FEE: $ PERMIT#
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