HomeMy WebLinkAboutBLDP-24-581 0\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY y14RMOr. ^ MA DATE 6 PERMIT#�4� -ay"5 )
JOBSITE ADDRESS 6a D QY Vr R(Tee C r tcfc OWNER'S NAME NAc e n
OWNER ADDRESS 64). D air rn6 Tee C t rcic TE�'o ')g$ -4762r FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:®. PLANS SUBMITTED:YES 0 NO 0
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 / _
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET a
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. YES 15 NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY INSURANCE POLICY® OTHER TYPE OF INDEMNITY 0 BOND❑
• OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
I Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE ONLY: OWNER❑ AGENT❑
SIGNATURE OF OWNER OR AGENT
L 1 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 all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ./
PLUMBERS NAME 6 16dtyce,( c LICENSE#c?4•71? SIGNATURE
MP❑ JP CORPORATION 0# PARTNERSHIP❑# LC❑#
COMPANY NAME 6-eao r ySe)fi 4'/u E
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CITY 41' IArn^' STATE nilZIP bal53 TEL(_S�')$icQ"4'6a-
FAX CE1(���-) T 3 Cf EMAIL sc'IFe%to. e YA-401-LO»+
ROUGH PLUMBING INSPECTION NOTES BELOW I►OR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT [
FEE: $ PERMIT #
PLAN REVIEW NOTES