HomeMy WebLinkAboutBLDP-25-145 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY r1 ;?INNn MA DATE L- LL-1 _2 S PERMIT# I3 C_p 13-zs` 7`1 r
JOBSITE ADDRESS i ? c rl{' OWNER'S NAME -IC 1AV
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL LY
PRINT ,!
CLEARLY NEW: RENOVATION:❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO❑
FIXTURES T FLOOR-4 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 — FEB 2-5
ROOF DRAIN
SHOWER STALL BUILDING DEPAR• LEN
SERVICE I MOP SINK —
• TOILET
i URINAL
WASHING MACHINE CONNECTION
i WATER HEATER ALL TYPES I
WATER PIPING
OTHER
1
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0'NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Er- 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 accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be' • ce with inent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME �' ` `� LICENSE# 40 R1 SIGNATURE
MP ❑ JP Ld CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME ~���%� 5 PLUWAV itl({ ADDRESS 3 St) l Off/ r
CITY , L�vu V\1 C STATE 11\ 1,1''� ZIP (') _E:,'y"G TEL ] 7(/- b�.7 i 59 2-
FAX CELL EMAIL pa ids ip/Gimb ny d D 7 ydA1),
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