HomeMy WebLinkAboutBLDP-17-003128 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY I t0 MA DATEa 9 PERMIT# A/2/3- CVV( O
C
JOBSITE ADDRESS 1 r WNER'S NAME
OWNER ADDRESS 5 Abut r-T R E C EL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EtUCFATIONAL ❑ RISI ENTIAL
PRINT C 02 2016
CLEARLY NEW:[11RENOVATION: ❑ REPLACEMENT: ' PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR-, BSM 1 2 3 4 D }9y � I M NY 3 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
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its sub lal equivalent which meets the requirements of MGL Ch.142. YES NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE T E OF 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
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
'a; CHECK ONE ONLY: OWNER E 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 r to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complianc ertinent provision of the
Massachusetts State Plu ..ing Code and Chapter 142 of the General Laws.
PLUMBER'S E Gv D/ M4 [0/ L SE# / q.6, SIGNATURE
MP JP ` CORPORATION❑# PARTNERSHIP❑.# LLC❑#
/ fr'1-c L1JCOMPANY NAM ADDRESS <—�/
CITY •
STATE ZIP O2b 7 j TE r l Q
FAX CELL EMAIL
NT
ROUGH76WIL
PL.
PLUMBING/� IN�SPEECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
. Ok L/�--l� 1062 / Yes No
` THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
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