HomeMy WebLinkAboutBLDP-18-006098 f.."r
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY /f retie±\ MA DATE S - I-I T PERMIT#1*.Dn J3'—OC'adF
JOBSITE ADDRESS Q FvoDcRs-i- 4 ne OWNER'S NAME n
POWNER ADDRESS t`7 13laPr1)CASf" L./tnt TEL(t°"$S°$'-4.766 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL fg—
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CLEARLY NEW:E RENOVATION: ❑ REPLACEMENT:[X PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR-+ BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE _
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
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DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER I _
DRINKING FOUNTAIN .
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) _
KITCHEN SINK
i LAVATORY -
ROOF DRAIN
SHOWER STALL
i SERVICE I MOP SINK I
TOILET f r -
URINAL / ).
. i WASHING MACHINE CONNECTION ' _Cik
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I WATER HEATER ALL TYPES
WATER PIPING I -
OTHER TGfAnak &Ioe- (
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i 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 THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY . OTHER TYPE OF INDEMNITY ❑ 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 11
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 compliance all pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ^'`1 J(
PLUMBERS NAME 6 °1ey s:"-I LICENSE# - 7I Y. v !f�SIG ATURE
MP ❑ Jp L-a CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME 6�1?-ySelP-P(wnas 06- CC'' ,C cc ADDRESS LlI S17"4 E12 &ft oe
CITY (.ti, ktmo.th -3 �s
STATE YP ZIP b�`' TEL( �O — /C(3 L/
FAX CELIC --/- 1(13 Y EMAIL S-eIFe tiae„y4,...to„,
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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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FEE: $ PERMIT#
PLAN REVIEW NOTES
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