HomeMy WebLinkAboutBLDP-20-001990 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY 1(1 r'd12 L�y MA D TE /Ci T/// `� PERMIT#A-O�OO-CO MO
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JOBSITE ADDRESS /i111/ OWNERS NAME_ l�'C
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[
PRINT
CLEARLY. NEW: ❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMI I I E.D: YES ❑ NO
FIXTURES Z FLOOR BSIv1 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
ROOF DRAIN
SHOWER STALL ,16.0L
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
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 TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 7 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 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 co p nce wit --rti t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME / / e r r /j' ' LICENSE# / / .r '� GNATURE
MP ❑ JP 5 1 CORPORATION❑# PARTNERSHIP❑.# LLC❑# ,,/
COMPANY NAME ADDRESS / f% (/(1/ i 9/�'"a
CITY .) ,4r 0-e/ -7 STATE S ZIP c9 r 6,1, 4' V TEL/11? Z� /tC
FAX CELL EMAIL 1 1 y i 1' l .G/' e 4` ),
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY
_____L INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT El ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
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