HomeMy WebLinkAboutBLDP-17-000793 6c-- j / cusp
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK .1
=_lw CITY ""t V L/ MA DATE g PERMIT#1942P17-147° 77
JOBSITE ADDRESS 7 1015 64 V > OWNER'S NAME
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YESC1NO❑
FIXTURES 7 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
OTH
y/2- i
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YE NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYP F 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.
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 ac o the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance w inent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBE ' AME pi4mpflu-rcy,gtmEN,E# /�� SIGNATURE
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AIRPORATION ❑# PARTNERSHIP❑.# LLC❑#COMPANY NE i ' ADDRESS �y� JU r 1�6
CITY / fi//0 (40 C / I STATE /4 ZIP oz J TEL
FAX CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
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,v,/6, ' 7 9/1 in/1-- ti Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
tb FEE: $ PERMIT#
PLAN REVIEW NOTES