HomeMy WebLinkAboutBLDP-18-003785 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY / " CALL /\ MA DATE !'c -^ 23 PERMIT#�l,Ll��'j7-iv 5/75
9- S' - CaLLI Roe
JOBSITE ADDRESS i OWNER'S NAME
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL`
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES E NO VI
FIXTURES Ti. FLOOR--I BEN 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
LAVATORY
ROOF DRAIN
SHOWER STALL •
SERVICE I MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION .CX)
WATER HEATER ALL TYPES
WATER PIPING (Pcx\ L
OTHER C4(j't_
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YE NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ 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
1` 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 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 corn 'ance with all Pe,inent pr i 'on of the
Massachusetts State Plumbing Code and Chapter 142 of the G eral Laws.
PLUMBERS NAME asC6 ce1f"L�i-1 LICENSE# SI NA E
MP¶ JP- /r) t S- etCORPORATION =/ 76 PARTNERSHIP❑.# LLC❑#
COMPANY NAME (- * ��d //
�t/G" �(✓/sV6-' ADDRESS 3CY/1/62/,�54
CITY ye /14 d i� STATE 4* ZIP Oa-6-7/ TEL 5L1I-73 7, r?60f
FAX CELL EMAIL 6 O y y.,43 6 l-!( -
ROUGH PLUMBING INSPECTION NOTES
BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT fE
PLAN REVIEW NOTES