HomeMy WebLinkAboutBLDP-17-006137 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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T, CITY Lc) VA �'6o v MA DATE �� '�v —/ 1' PERMIT# 64/9P"/7 (Q/ 7
JOBSITE ADDRESS 4tq -k.x.y 9I/6- OWNER'S NAME 1 -7EOS • 74 fit 5/ '•}
POWNER ADDRESS 1.1 -CR'ov e, TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT PLANS SUBMITTED: YES El NO aCLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:
FIXTURES 1. FLOOR-4 BSIVI 1 2 3 4 5 6 7 B 9 10 11 12 13 14
BATHTUB I' _
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM _ _
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM _
DEDICATED GRAY WATER SYSTEM ' ( '
DEDICATED WATER RECYCLE SYSTEM :-.:\)ft
DISHWASHER -
DRINKING FOUNTAIN
FOOD DISPOSER _
FLOOR/AREA DRAIN
r - -
INTERCEPTOR(INTERIOR)
KITCHEN SINK
i LAVATORY of •
ROOF DRAIN _ _ 1
SHOWER STALL t' _
SERVICE/MOP SINK 0,4 I 6 33
TOILET 02..
URINAL
WASHING MACHINE CONNECTION I
WATER HEATER ALL TYPES
WATER PIPING
OTHER
I
! INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO
i
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSU ER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachuset eneral Laws, d that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER AGENT E
SIG RE OF OWNER OR AGENT
LU I hereby certify that all of the details and information I have submitted or entered regarding this application e and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will b n co Hance with all P ' nt p ovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
CZA—NPLUMBER'S NAME LICENSE#.�C(/9 r
SIGNATU E
MP❑ JP X. CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME Dot r/\ CG` ply 4" t ADDRESS i CAe71 MA1W 51,
CITY WeL71 Ot ANA STATE II/►t ZIP 015 5 I TEL
FAX CELL .,0`7 ?-.Z.3 „L t EMAIL
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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