HomeMy WebLinkAboutBLDP-17-001628 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
V— CITY 74Rp 02T MA DATE 2- /f—�‘. PERMIT#r gp /7-00_4211
JOBSITE ADDRESS 2 a //4Z rflif Z/47 /J/?, OWNER'S NAME .9ZA1Av 92A/ts
OWNER ADDRESS / 61' Z, '4Z L/4 U k? TEL Slci° J/2 ' 20 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:f❑ RENOVATION: E REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 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 311
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 /d 4c 4'Flow
l 11. ' d.-iraN
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 1O ❑
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
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 compliance with al Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# SI ATURE
MP❑ JP CORPORATION ❑# PARTNERSHIP❑# LLC�# I( 707 y
COMPANY NAME Mic-4r C S y' q 5'o f ADDRESS 2 p R O sy ec r 4U-r'
CITY //(/ - y! /t STATE /27 4 ZIP C2 a 6 `9 3 TEL �S1 e7- 2Y 2 - G/K
FAX CELL 51c.¢- ,22 - cagi EMAIL /Vei✓
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