HomeMy WebLinkAboutBLDP-18-002992 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY MA DATE PERMIT# ��-dd O�QFg
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JOBSITE ADDRESS / U S r0,4 Z r-(v a� OWNER'S NAME a�
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB j
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM I _
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM _
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN _
FOOD DISPOSER
FLOOR/AREA DRAIN _
INTERCEPTOR(INTERIOR)
KITCHEN SINK
i LAVATORY
': ROOF DRAIN 1
SHOWER STALL
SERVICE/MOP SINK
' TOILET Ii
URINAL
. WASHING MACHINE CONNECTION
I WATER HEATER ALL TYPES j I
I -
WATER PIPING t/ 1
OTHER 1
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INSURANCE COVERAGE: �
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES�J NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY tr OTHER TYPE OF INDEMNITY 0 BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
i` Massachusetts General Laws,and that my signature on this permit application waives this requirement.
ri CHECK ONE ONLY: OWNER 13AGENT ❑
SIGNATURE OF OWNER OR AGENT
I I hereby certify that all of the details and information I have submitted or entered regarding this application a- '-.e a . accurate to best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be i '•mpli- ce with ent p vision of the
Massachusetts State Plu i Code and Ch te�142 off the General Laws. di �w
PLUMBERS NAME ✓ �(i/(� `/�cti`� LICENSE# y)O. SIGNATURE
MP ❑ JP CORPORATION El# PARTNERSHIP ❑.# LLC #
COMPANY NAME 7//�' e4 ��I 7` ADDRESS 7G l o 4(96.-- e.e, A /to A
CITY I/4 t wr C.( STATE 7-4 T ZIP 0 ‘ TEL r TEL 01 g,.)- t 7
FAX CELL EMAIL 4 --//74 L 4 6 0 G"1-tr /
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY
FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT tt
PLAN REVIEW NOTES