HomeMy WebLinkAboutBLDP-20-004337 y� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
== ' CITY MA DATE PERMIT# boafrao-cu y/57
.�.. JOBSITE ADDRESS / 7 6�`L/ /'rtc/ .DA OWNER'S NAME (7D/tit e
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO ►!
FIXTURES 7. FLOOR-I 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 R E E I V F a
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) I
40 1[
KITCHEN SINK -
LAVATORY a 4
ROOF DRAIN BUILDING DEPARTMENT
SHOWER STALL �-- —r-
SERVICE/MOP SINK
• TOILET
URINAL
WASHING MACHINE CONNECTION l
WATER HEATER ALL TYPES `
WATER PIPING
OTHER
I — INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES U4 ❑
IF YOU CHECKED YES, PLEASE INDICATE THETY E 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 in c�e with all Pertinenpro/vision the
Massachusetts State Plumbing Code and Chapr 142 of the General Laws.
PLUMBER'S NAME `(/ bilea.e -� LICENSE#// ' IGNATURE
MP [ JP❑ CORPORATION[ #� PARTNERSHIP❑.# LLC❑#
COMPANY NAME —Cep1�1'\.I` ey„ ADDRESS lit )/ ? '—
CITY W d, STATE /" ZIP A 6 ' TEL 3 A-f- I ?
FAXN (D 3 CELL 3�?7 2(41 EMAIL d7A-70
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑
FEE: $ PERMIT ft
PLAN REVIEW NOTES