HomeMy WebLinkAboutBLDP-19-002058 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY V CCU' !Yl(,)tn' MA DATE b - I PERMIT#/. /�1�'/?"0"0�0y- f
JOBSITE ADDRESS ( e �) J o .` 1 [ OWNER'S NAME l:601a.
OWNER ADDRESS /(),IIV/. C_. TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL E EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: E RENOVATION:[REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES Z 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
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING I
OTHER
INSURANCE COVERAGE: u
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO ❑',
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 04I () 2 16
LIABILITY INSURANCE POLICY I717 OTHER TYPE OF INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage requireeroy Cr 142 of the'
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 wit all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. G
PLUMBER'S NAME LICENSE# 15 d /. SIGNATURE
MP 1771 JP❑ CORPORATION Lr# PARTNERSHIP C. LLC❑#
COMPANY NAME J y l(A 1P L) I'1C( ___- ADDRESS '}7/1 Le)jorgio(A) (>-b1iLA R .a
CITY 5, l i is W' c ukt4 STATE 1-.Acr, ZIP 621. Z TEL S 0,5 3 7_
FAX CELL Au% r' EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY
FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
U e //- /) `' �^ FEE: $ PERMIT#
PLAN REVIEW NOTES