HomeMy WebLinkAboutBLDP-20-001717 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY 14G`�'d p c /MA DATE ' 3v—/.9 PERMIT#/ ✓/ O Oc 117
,, JOBSITE ADDRESS 30 E// 1 S G( /- OWNER'S NAME P,,,, d Kt,V ex
POWNER ADDRESS id Lf/, S C f GC 1< --. TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL�------
PRINT
CLEARLY. NEW: ❑ RENOVATION: REPLACEMENT: ❑ PLANS SUBMI I I ED: YES❑ NO❑
FIXTURES Z FLOOR-4 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 1
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£ NO 0
IF YOU CHECKED YES,PLEASE INDICATE THETY E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND 0
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 provi ' n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ��
PLUMBER'S NAME LICENSE# I 3.25 4 - GNATURE
MP ❑ JP❑ CORPORATION Ell s/6 N PARTNERSHIP -# LLC❑#
COMPANY NAME )9C OL—fh ADDRESS
CITY 6iply STATE✓Y?C& ZIP ) 6 6 TEL
FAX CELL M y5757 EMAIL j 91v (yJ y`\-'L �' vC���/-^'"�
• a2#
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY
FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
// /a FEE: $ PERMIT 1t
((( PLAN REVIEW NOTES