HomeMy WebLinkAboutBLDP-17-003839 ,,•— MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
/ CITY YLW " ' MA DATE 1 2 1-1! 7 PERMIT# %, P 17
JOBSITE ADDRESS 461 (D)D ►' `Iv) ��k / Co,q 'F NAME J V VE
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL�a
PRINT
CLEARLY NEW: ❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES;—NO❑
FIXTURES-1 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 _ _
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN _
SHOWER STALL t _
SERVICE I MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION I
WATER HEATER ALL TYPES I
WATER PIPING I _
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YE NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYP F COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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
J 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 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 complian e with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Y(Y'& �0' '0-q 0 1/'�-- LICENSE# ��q� ( SIGNATURE
MP JP ❑ CORPORATION ❑# PARTNERSHIP❑.# LLC ]#
COMPANY NAME 1�o c-(-unov 1 �lJ I'��f ADDRESS A/0 4 II_..5 ._._ _._ _..__..._.
CITY �� STATE V,A4 ZIP 0.2--- .
b 3 I T 11 ---41175
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FAX CELL EMAIL AN 24 201?
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LDILN1! iG ( `f (_/`-
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
pz._ Yes No THIS APPLICATION SERVES AS THE PERMIT((' //k7-7/ ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES