HomeMy WebLinkAboutbldp-16-005774 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
1 / CITY I 0/17- MA DATE PERMIT#,8zd 19 /t t O 677y
JOBSITE ADDRESS A ANW NAME
POWNER ADDRESS :5/3114` TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ 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) t
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK _
TOILET
URINAL
WASHING MACHINE CONNECTION ,J/
WATER HEATER ALL TYPES
WATER PIPING
OTHER
_------
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TY 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: OW ER ❑ 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 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 compliance e ent provision of the
Massachusetts Stare Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S (l9-Z1/ 1(f- `a/° # /5% 7i SIGNATURE
MP JP
❑ CORPORATION LI# PARTNERSHIP❑.# LLC #
COMPANY N ME ADDRESS 15
CITY // 7t(lV'777L
STATE ZIP �� TEL '" w�
FAX CELL,5 �j,�• MAIL
ROUGH PLUMBING INSPECTION N TES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
F.671. 1,4_0 0,4 t 0" r/P6 /6 Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES