HomeMy WebLinkAboutBLDP-24-865 0I--r7 T"12_it 5� _Foaki) j.�.5,d�
MASSACHUSETTSp UNIFORM APPLICATIO FOR A ER IT TO PERFORM PLUMBING WORK
ILI CITY Y. /f , 0 f/T MA DATE a b C,f PERMIT#gt DP- ?6,s
JOBSITE ADDRESSke5_____,ql Z? OWNER'S N I"L/ ,)A / J/ Ci-
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TY COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: ❑ PLANS SUBMITTED: YES NO❑
FIXTURES T 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/OILISAND SYSTEM
DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM _ _
_ T
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER •
DRINKING FOUNTAIN
FOOD DISPOSER _
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) iiR_ - �® B
KITCHEN SINK . '�' ,
LAVATORY r% 2
ROOF DRAIN /U Orr 1� 2�1� _
SHOWER STALL
SERVICE/MOP SINK
TOILET BOIL DIN =1'( tAi1T,ti EN i
t
1 URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES A
WATER PIPING 1` T
• OTHER /
T ,
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 TYP OVERAGE 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 I hereby certify that all of the details and information I have submitted or entered regarding this application are tr and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co liance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _ �,
PLUMBERS NAME!� D I +")►V rC 0 Cb v" ICENSE# Q.�' SIGNATURE
6 i,
MP-P[11/ CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME j1-0/J0R---- >P(,( t ADDRESS 2 i?N7*10W / /P"�
CITY )1 id D (/ `l STATE Mil ZIP 0lb 7 3 TEL 5O _ 10'0 sd 3
FAX CELL EMAI ( �� #j �LO� (�_
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