HomeMy WebLinkAboutBLDP-24-934 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMITc/TO PERFORM PLUMBING WORK
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s�, CITY G�rrYI D:J eCf MA DATE J PERMIT# 73 Lpf --)Y^ 1
3�10 Heft / E L/ ted
JOB TE ADDRESS � ((,vCX�1OWNERS NAME �1� y; Z
POWNER ADDRESS SGjm e. TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:E RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES❑ N0�
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 1
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 1
SERVICE I MOP SINK p-
URINALRCCE ! V..ED
WASHING MACHINE CONNECTION 1
WATER HEATER ALL TYPES ►Jn1i _ .
WATER PIPING ICU Yl
OTHER _
1 BUI_DING DEPARTMENT
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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, NO E
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW .
LIABILITY INSURANCE POLICY 9k 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
[° 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 I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate the st of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co ance th a erti t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1 ��
PLUMBER'S NAME LICENSE#3I . SIGNATURE
MP ❑ JP CORPO TION❑# PARTN SHIP❑.# ' LLC❑#
�ISJ' ag ,61�( ytGl �COMPANNAMEADDRESS O / ie
CITY arciO) C/A STATE 77i/9 ZIP T L
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FAX CELLSjO `'776- gi I EMAIL Or ..) r y/U ali
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