HomeMy WebLinkAboutBLDP-19-006557 ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM/PLUMBING WORK
71 CITY / i MA DATE `PERMIT#/DP/7^03- '5
JOBSITE DDRESS �� OWNER'S NAMEI \jA/_Y U. i./A __
POWNER ADDRESS , , , TEL 'FAX w
TYPE OR OCCUPANCY TYPE COMMERCIAL[ EDUCATIONAL LI RESIDENTIAL kj
PRINT
CLEARLY NEW:Q RENOVATION:0 REPLACEMENT: ; PLANS SUBMITTED: YES 0 NO
FIXTURES 1 FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB IN
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CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM r--- r ,
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DEDICATED GAS/OIL/SAND SYSTEM r f
DEDICATED GREASE SYSTEM
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DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM ' '`- - i
DISHWASHER = r- - r_T_ „_.�. __ _. !
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN ti i I
INTERCEPTOR(INTERIOR) PIIMILIIIII Milt I €
KITCHEN SINK , ! Ii_ 7 __ ,
MTV^ _�
LAVATORY 4 `
ROOF DRAIN
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SHOWER STALL . — _. _ { 1 I
SERVICE I MOP SINK I
TOILET i i I , 1. ,i_ _ __,
URINAL t""
WASHING MACHINE CONNECTION 1 i I _
WATER HEATER ALL TYPES
WATER PIPING r �
OTHER L._ i i 3_.:_
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES X NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 14 OTHER TYPE OF INDEMNITY i BOND 4_.
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 n AGENT U
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. ^ 1.-11
PLUMBER'S NAME &;►'ICE T. ,whi-i-deij 1LICENSE# 159a0 1 SIGNATURE• --
MP X JP CORPORATIOND# 1PARTNERSHIPLI# LLCO#
COMPANY NAME 10, VPXncV1 hl'ie II ADDRESS as VI (la .e „ II`x
CITY 11), sha m STATE ZIP 1V _..,.. , ., TEL I,..5 2- J45- 1 I0U�
FAX ' CELL s EMAIL
Fes'
' 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