HomeMy WebLinkAboutBLDP-18-007337 s� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
-e-L CITY �1r (?t1}� MA DATE Z 1 iq PERMIT# ��"�7l
c �� n 5 . �P �l l�-en Co\ �e r
JOBSITE ADDRESS.rI�S CA-Le k'� �� fa- 0 N R'S NA E
POWNER ADDRESS C` 61 C Q C�(1 et v'e_ /-h \/4f ri L• r4 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL E RESIDENTIAL
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CLEARLY NEVV:(,�J RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR-4 BSM 1 3 4 5 6 7 B 9 10 11 12 13 14
BATHTUB (t c'\krQ ,
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM , ,
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICA I EU WATER RECYCLE SYSTEM
DISHWASHER 1_____ . __________] • ' ' ,
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK I 1
LAVATORY i
ROOF DRAIN
SHOWER STALL t
• SERVICE I MOP SINK / -'
TOILET i ` r
IIII
URINAL • /(�/) „6)7)
WASHING MACHINE CONNECTION i / '
WATER HEATER ALL TYPES
WATER PIPING _
. OTHER
1 . 1 \
1 INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESO 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
I UABIUTY INSURANCE POLICY V OTHER TYPE OF INDEMNITY ❑ BOND 0
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 hereby certify that all of the details and information I have submitted or entered regarding this application are true nd accurate to he be of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in corn e with all P ne rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER' AIM 1CNNl AQ'5 f` LICENSE# i CZ C6 SIGNATURE
MP JP❑ CORPORATION❑}# PARTNERSHIP❑.# LLC[gift 3 7 C Z C
AckNACOMPANY NAME !- ne( Q tbf "ADDRESS C.6 7 (Cj1rO j e /-'°1
CITY by.A S 6`t° ^STATE L 4 ZIP 0 b 3 0 TEL
FAX CELL 6-d v J 17 (i6i EMAIL ! ke tf vrfk C(36)CbK c s t /.e 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 It
PLAN REVIEW NOTES