HomeMy WebLinkAboutBLDP-17-001651 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 1
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7 JOBSTrE ADDRESS V/Ata L/s�pyil n '11/ AcT6 OWNER'S NAME . (r A,e/1
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POWNER ADDRESS 7/ '( /7 Tactic--ZIOc-7Y3yFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL❑ RESIDENTIAL)‹
1IRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACO N1 PLANS SUBMITTED:YES 0 NO E
FIXTURES- FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
I CROSS CONNECTION DEVICE \ -
DEDICATED SPECIAL WASTE SYSTEM •
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM 1
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
I FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY -
ROOF DRAIN
SHOWER STALL -
SERVICE i MOP SINK '
TOILET • '
URINAL -
WASHING MACHINE CONNECTION
WATER HEATER AU.TYPES -
WATER PIPING -
OTHER -
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equ iralent drdr meets the requie ne its of MGL Ch.142 YEX NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKJIG TIE APPROPRIATE BOX BELOW
1 LIABILITY INSURANCE POLICY* OTHER TYPE OF N)EINTY 0 BOND 0
OWNER'S INSURANCE WAIVER I am aware that the licensee does mot have the insurance coverage required by Chapter 142 of the
Massachusetts General La—"arnd thaFrm signature on this permit application waves this requirement
CHECK ONE ONLY: OWNER AGENT❑
SIGNATURE OWNER OR AGENT
t hereby certify that an of the details and 6nfomnalon I have submitted or aided regarding the application are true and accurate 51he best of my knowledge
and that ae plumbing work and installations performed under the Pant Wined for this appirabon we be Jr conpiance wh-al rhnent provisron of the
Massachusetts State Plumbing Code and Chapter 142 of the General laws. / �_
IPLUMBER'S NAME W)19A.L0e-.�°E4..� LIGEISE# //9 7 SIGNATURE
I MP3 JP O cORPORA11 Npe#Zr[?1 C PARTNERSHIP 0# LLc 0#
COMPANY
NAME AGe=Q- fr c�7i. Y %mi 12 4E-f AI&6- ADDRESS J3 1-:-//.2e r/4 LLi
CITY Pk I t)ri►Ile- STATE P4M zp a274 TELSIf-C 4'�-GCS
FAXSt ` "���� CELL LL EMAI/_�T /I ✓A3r7 %' sLiS L£1
( OUGH PLUMBING INSPECTION NOTES
IMEOW FOR OFFICE USE ONLY
FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PERMIT #
FLAN REVIEW NOTES