HomeMy WebLinkAboutBLDP-20-002767 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
_ CITY K1M /2 d L���`1 /MA DATE �/ ~�� PERMIT#
��— JOBSITE ADDRESS 22 7Sc //op R OWNER'S NAME �w ect OWNER ADDRESS 9' - c' 74-2 Ai ' TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[�
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CLEARLY NEW: RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMI I I ED: YES❑ NO❑
FIXTURES Z 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/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 3 61•
ROOF DRAIN
SHOWER STALL { T.
SERVICE I MOP SINK
I TOILET
URINAL
WASHING MACHINE CONNECTION I /.
i WATER HEATER Al I TYPES
WATER PIPING I.
OTHER )' /" 5,‘/\ 3 I.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 9---/NO 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY 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� 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 Plumbin Code and hapter 142 otthe General Laws.
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PLUMBER'S NAME ° LICENSE#
1 j�5�. `� SIGNATURE
MP Er JP ❑ CORPORATION Ly'# ,j J 6 e-{ PARTNERSHIP❑.# LLtgai#
COMPA Y NAME —�-� ' ADDRESS
CITY Y J / U STATE ZIP C G6) TEL WY 7?3 < )D
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FAX 5C c CELL�C S76 L 3 �t EMAIL]c..i�JSI' ?(J 11.^�-h, y 1�L tL, Vf-€12cA'_
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
THIS APPLICATION SERVES AS THE PERMIT Yes No
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//C) L' FEE: $ PERMIT# •
PLAN REVIEW NOTES
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