HomeMy WebLinkAboutBLDP-17-000681 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
l ' CITY yRor `J Jk4 MA DATE $ ( ( 14 PERMIT# IJ/-r,P-17 Ot?0tri
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} JOBSITE ADDRESS 1 k 1p4.„ft-_,n� /A 11.-. \Xcvl.-MAA"-( OWNER'S NAME 4-
POWNER ADDRESS S ik1N1/4-i - TEL-7'8 -19 g 41 X
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:IFI/ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR-F BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE I
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
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING l
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 TYP F COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY U ''NCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND ❑
OWNER" ,4' a N WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massa •_ ral Laws,and that my signature on this permit application waives this requirement.
6 "ii
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
I hereb ify 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- -slumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME rt"-('u`-'•- <y'w("4''J LICENSE#1 3 o'Z'3
SIGNATURE
MP❑ JP[l- CORPORATION ❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME yf✓ ��."/ pc��•-,��.;, ADDRESS -7 - (-3 la ;,.�,}c1• �v �_
CITY S. VA,r,t.1_,... Pip STATE ' ZIP v 'LC-f-Csz LI TEL.S.4F-- 38>-`'C?
FAX CELL :7d —9 .l - -7 i oS EMAIL�iG' -'; '- 'PC ....),1/2,4: �4 p 30.44;L-L„---\.
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