HomeMy WebLinkAboutBLDP-24-975 l
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. I /MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
- ? CITYY Y/i /2Mt17z71MA O lei DATE G— PERMIT# QLAP Zk— I
�, JOBSITE ADDRESS1,__,___KLI. Zg OWNER'S NAME (,1"►12E 5 ( 01- J
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑
PRINT m/
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:El PLANS SUBMITTED: YES El NO lam'
FIXTURES I- 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 -r
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER _
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR 1 AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY v—,- - ' 4a E '` 1 :.v
ROOF DRAIN // �`
I SHOWER STALL — wierk r� Cret
SERVICE/MOP SINKG
TOILET .3,_ __. 1i URINAL
RUILJING �tNA �.
. j WASHING MACHINE CONNECTION /� E 3 ---7__'
WATER HEATER ALL TYPES
WATER PIPING _
OTHER LI 7`7)D lIt'/f: L
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 TYPE 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
t Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
,�
SIGNATURE OF OWNER OR AGENT
1 I hereby certify that all of the details and information I have submitted or entered regarding this application are true 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 complia a we wi Pertinent provision of the
Massachusetts State Plumbing Code
Code and Chapter 142 of the General Laws.
PLUMBER'S NAME git,A) PM-0//VP01.4..e.5 LICENSE# l` Qc SIGNATURE
MP ICJ' JP TI.� CORP RATION I # PARTNERSHIPJ � 0.# LLC El#
COMPANY NAME l0 ��� ° — 7 .----
ADDRESS ' MP!iP l 1/ ()
CITY '1� 72M'4 STATE 1`WZIP 0 Z‘ 7 TEL28 ,Jf? 6 3 !q3
FAX CELL EMAIL —0' CV Li ( .3
I ilia
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