HomeMy WebLinkAboutBLDP-20-004375 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY ", J jL��r�t%1,,� �� 1 MA DATE n F PERMIT# '� P� dV`/ �3
JOBSITE ADDRESS Y iO3 ' OWNERS NAME
POWNER ADDRESS <)t1n A �� TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIA EDUCATIONAL 2---- RESIDENTIAL?
PRINT
CLEARLY NEW: ❑ RENOVATION: REPLACEMENT:E.---'"-.- PLANS SUBMITTED: YES E NO❑
FIXTURES 7 FLOOR—+ 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 W
DISHWASHER E11 V E D
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN IN L Y 77.-"SHOWER STALL .
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER f (6. LA4 i P__.. /'
/ -
INSURANCE COVERAGE: '/�f
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES E NO ❑
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY D''' 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
k I hereby certify that all of the details and information I have submitted or entered regarding this application are true and acc to 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 wit ertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. '
PLUMBER'S NAM1E "'" LICENSE# J3I1 ,
SIGNATURE
MP �,, JP E CORP RAT, N❑# PARTN SHIP .# LLC # i?..2::::,
COMPANY NAMEitb l� ) ADDRESS 4 Tt — J
CITY yytf � STATE / 1 ZIP 0 -.'� TEL
FAX CELL ? () )9_ MAIL
7, l'
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
le6/1 04 Q�, / THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ --
//q1/4o FEE: $ PERMIT#
PLAN REVIEW NOTES
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