HomeMy WebLinkAboutBLDP-17-000927 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
_:l. CITY_ fi R/Y)O /C MA DATE V/9//k PERMIT#Af- /7 CaUU gJ,7
A�" JOBSITE ADDRESS 161 (39- }/th Pfo c k /c-c! . OWNER'S NAME . %g_!'I e y C k`
P OWNER ADDRESS r . / t i k FAX
_3ci,f_P FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAJ
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
FIXTURES T 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/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM _ _ _
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER - ! ) t .
DRINKING FOUNTAIN
FOOD DISPOSER
I FLOOR/AREA DRAIN _ _ _
INTERCEPTOR(INTERIOR) ' _ _ _ _
KITCHEN SINK
LAVATORY {
ROOF DRAIN _ —
SHOWER STALL _ _ _ ,
_SERVICE i MOP SINK
TOILET
URINAL _ _
I. WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING — _
OTHER
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_ I I _
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YEK NO 0
'I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CIECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND 0
+ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
I Massachusetts General Lamm-and thatifiv signature on this penult application waives this requirement
CHECK ONE ONLY: OWNER AGENT ❑
SIGNAT6REEWNER OR AGENT
II I hereby certify that all of the details and information I have submitted or erred regarding this application are true and accurate tg the best of my knowledge
and that all plumbing work and installations performed under the perm issued for this application will be in compliance I rtineht provision of the
I Massachusetts State Plumbing Code and Chapter 142 of the General Laws_ _—r /
PLUMBER'S NAME �' R L C 4�'�,(�' UCENSE# �V 1 -_
//9 %_ SIGNATURE
MP, JP❑ CORPORATIONN#.2'I 11 C PARTNERSHIP 0# LLC❑#
COMPANY NAME 4=r��. . 44/1 f i,it-'t f A t;6— ADDRESS -3 Lii u /,1 It
CITY 12Ii t 0 vri lie- STATE}f 4 ZIP C-'-2"74 a TELS -C t4-S CS 9
? FAX Si-'4gG'L r0' CELL ,{� -�
- EMA v"Ale:97 6'�`:"4`kt LitS/d ,i' -T.-
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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