HomeMy WebLinkAboutBLDP-17-002157 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
__. CITY /0 MA DATE 10 PERMIT# 014P-J/(O 0267
JOBSITE ADDRESS 28 /") .`- tt. ,„,__ OWNER'S NAME R-L) 'e P
l /
OWNER ADDRESS 20 c�I� toci. TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:El RENOVATION: r2 REPLACEMENT:❑ PLANS SUBMITTED: YES El NO❑
FIXTURES 7 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
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER 7{
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK >(
LAVATORY-
ROOF DRAIN
z SHOWER STALL
SERVI /MQP SINK
I mTplLE --4
URINAr Iw
WASHING MAHI E CONNECTION
'"`IIVAT IEATIR LL TYPES
WATiR'PIPIN� I x
4Tk#FR,e.�...d
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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 A NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY g_ 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 El
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are tr nd ac urate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in anc ith all Pe ' sa provision of t
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME �C � LICENSE# 32.00 SIGNATUR
MP El JP FA !! CORPORATION [I]# PARTNERSHIP❑.# LLC El#
J COMPANY NAME txn,,,lc-e. �jj,/v►��j4� ADDRESS 76 5anft ied
CITY $' VAC4rdY74 STATE )91 r7_ ZIP O2&fr J TEL "
FAX CELL `.s''ZZ —'575-7 EMAIL J*dv.wi-to Q C579fee
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