HomeMy WebLinkAboutBLDP-20-002871 M SSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY '� MA DATE I G/ PERMIT#j./040.00 of7/
JOBSITE ADDRESS )---3 5 C/f UUr WNER'S NAME
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL,
PRINT
CLEARLY NEW:❑, RENOVATION:Ej REPLACEMENT: ❑ PLANS SUBMI I I D: YES❑ NO❑
FIXTURES 1 FLOOR-4 BS1v1 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I 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
CO 0
I Ir
• INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO-
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICYt OTHER TYPE OF INDEMNITY ❑ BOND hlr"1Z! .1 Q ?niq
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage+quired by Chapter 142 of the
1` Massachusetts General Laws, and that my signature on this permit application waives this requireme t.Bu k?LA "- ��i�
Y -
•
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 mpli nce ' all Pe ' provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE#y0)03 t SIGNATURE Li4 .
MP ❑ JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME G' V`/C' >arfie 3 0Y5' ADDRESS r�� Cc(d)
CITY C'L'Ji 4C 1 v i ' 1 STATE +` )M ZIP 0� TEL 5- a �7� ��
FAX CELL EMAIL � � �t/�� ,
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
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