HomeMy WebLinkAboutBLDP-20-004908 1 s MASSACHUSETTS UNIFORM APPLICATION FOR 9, PE MIT TO PERFORM PLUMBING WORK
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CITY ,' I ,i Z O L) MA DATE2 PERMIT# pp -CO. 00'
JOBSITE ADDRESS �� YMCA/ OWNER'S NAME
POWNER ADDRESS �,� 2j I TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCI EDUCATIONAL ❑ RESIDENTIAL s,_ ------'
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: ❑ .PLANS SUBMITTED: YES Or NO❑
FIXTURES 7- FLOOR-F 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 '
I LAVATORY �/
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK Y
TOILETS
URINAL I I
; WASHING MACHINE CONNECTION f ; t_g
WATER HEATER ALL TYPES k.....1,' 3WATER PIP G • ,64 i 1L - $1 #Z
.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO ❑
I IF YOU CHECKED YES, PLEASE INDICATE THE E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLIO 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
l' Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
k I hereby certify that all of the details and information I have submitted or entered regarding this application are t4 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 corm nce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER' ME ,r) _ LICENSE#1 d SIGNATURE
MP JP CORPORATION1111# PARTNERSHIP # LLC #
COMPANY/ME6I4� ADDRESS ✓v ( "/ ai
CITY V VT STATE Pfi.." ZIP V 7� 3 v 5q q 3
FAX CELL EMAIL
Lit/4
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY
FINAL INSPECTION NOTES
Yes No
FL0 THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
f `" L �O FEE: $ PERMIT#
PLAN REVIEW NOTES
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