HomeMy WebLinkAboutBLDP-18-001274 •• MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
�.V71 CITY ).:r ►A'. MA DATE —t f CP k.--2 PERMIT# 672r-6'U/ 71(
JOBSITE ADDRESS fig!-( aS P�cr 'I- Dvl 7r OWNER'S NAME(,G•' �'�
OWNER ADDRESS Y5 TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[�
PRINT
CLEARLY NEW: ❑ RENOVATION:EY REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 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 tj •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK ' 4
LAVATORY a, -
ROOF DRAIN
SHOWER STALL II
SERVICE/MOP SINK
TOILET
URINAL COI °!
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 41, 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
1' Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
'=l 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 c mpliance with all P nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME n v e-ri c)u eki LICENSE# M t 31 L.' SIG TURE
MP/ JP❑ CORPORATION ❑# PARTNERSHIP❑.# LLC❑# p
COMPANY NAME i`7 vrrG(,1 eg 1} ADDRESS I �� C " --✓�� �"' P°
CITY 0/104,17), tE--- STATE M/L ZIP ��'�' eJ TEL 455 �� Z"t`'Lt 2s
FAX CELL EMAIL
I-F I3-D
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
R62A__ 6,( THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
/7 FEE: $ PERMIT#
PLAN REVIEW NOTES
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