HomeMy WebLinkAboutBLDP-18-001285 4 6 0 vf i'
:- 17- 00
�` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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�� w CITY ,, ,_ MA DATE � %^ y PERMIT#/f1 /�'�fo24�
JOBSITE ADDRESS a „„�. l OWNER'S NAME
P OWNER ADDRESS I _ I TELL_,
FAX
t � _
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:® RENOVATION:a.., REPLACEMENT:00 PLANS SUBMITTED: YES 0 NOI
FIXTURES Z FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB MIRMINIMMIllillernilliMINKIMINIMMIIIII
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM ? _maimm mi.
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM 1.111M11111011111111.1EMIIMMINIMINIIIIIIMillillif
DEDICATED GRAY WATER SYSTEM _. �
DEDICATED WATER RECYCLE SYSTEM migarlimmtwanimpurnumimummincomme
DISHWASHER OM 1.1111111.1111111.1MAIW k
DRINKING FOUNTAIN sioMinii Y/ i '_ _
FOOD DISPOSER MIL.1111:101111WOWINIUM10111111,1100.111111111.111.11
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK11.111111,111.111.11ammassaiwaimsomtammitostammimi
LAVATORY
ROOF DRAIN
SHOWER STALL �, , ... . ® .
SERVICE/MOP SINK
TOILET
URINAL IIIIIIIIIIIIIIUIIIIMIIIIIIIIIMIMIIIIIIIIIIIIMEIIIIIIIIMIMIIEIIIIIIIIIIFNIIIIIMIOIMI
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHERMIMISWEIIIIIMMIIIIIMMUILIMMIlailailliMINI
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESX NO LLL„,'i
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY X 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 0 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 iance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME rlc, T. r1TF�t LICENSE# 00, SIGNATURE
MP Xi JPLI CORPORATION ED# ]PARTNERSHIPLJ#t LLCLJ#j .
COMPANY NAME La vex nCVI� j,f ADDRESS t�ls Vl,. Cu��x ,
CITY ,..,,Q,,, , Ta'!z t ... , ; STATE ZIP ! .'D TEL ,Ll._.__'7.y I .. .
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FAX r _li CELL EMAIL
L NW-
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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