HomeMy WebLinkAboutBLDP-16-004098 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
C:CIE1 A ifiO4 /p MA DATE l !S�-1'S PERMIT#/'�r-�/)`/6'"���/0
! JAN O15 EtADDRE S UI-A-0, 0v OWNER'S NAME
OWNER ADDRESS TEL FAX
s},�DIVDEPARI"„4Pra'
TY 4:Y 8CC11P9PlCYTYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL. '
CLEARLY NEW:0 RENOVATION:V REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO❑
FIXTURES 1 FLOOR-. ESM 1 2 3 4 5 6 7 6 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/MOP SINK _
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YEWL NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY 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
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 a e. rate to the best of my knowledge
and that all plumbing work and installations performed under the permtt issued for this application will be i co li all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /�
PLUMBER'S NAME LICENSE#8gc GNATURE
MPLa JP❑ nn CORPORATION 0# PARTNERSHIP❑# LLC❑#
COMPANY NAME C 2iA(4- -n4ti(i)L/ ADDRESS r.O, OK l 77
CITY—/ -IetaIG* STATE ZIP 02,‘, 'c TEL 5-h$`g4710
FAX CELL EMAIL
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