HomeMy WebLinkAboutBLDP-18-001382 M�ASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
[ CITY t ( MnFi ,oa1'- MA DATE el"i(3G ( 7 PERM IT# / P/i.-dciY72 _
JOBSITE ADDRESS 9\rr K`fizZoL f-04)(\--- OWNER'S NAME &torr(l Ki iti'/
POWNER ADDRESS I Og (416?P-1t i17s'itWwJ CC TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ 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
- H
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 t`t
ROOF DRAIN k
SHOWER STALL "47 SERVICE/MOP SINK _
TOILET
URINAL _ _ T
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES _
WATER PIPING _
OTHER ktD t0 i,ifpti 1
ot5i4.OE .1?-40 `nb4 I
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 OTHER TYPE OF INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER:I a aware that the licensee does not have the insurance coverage required by Chapter 142 of the
ie Massachusetts General Laws, and that my signature on this permit application waives this requirement.
_ CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
- 1 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 compliance with all Pertin ovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 711
PLUMBER'S NAME Ajtirt-lirS LICENSE# SIGNATURE
MP❑ JP t CORPORATION ❑# PARTNERSHIP LLC❑#
COMPANY NAME 01.431 H1L% tytY L 1 C"tC' - J-cy ADDRESS `a CvX .� "
CITY � 'P'S v�1� �,�� STATE N\k ZIP O� (12V TEL Ca"i/ rl—SV6 )
FAX CELL EMAIL me/\(�OecL� opik\\, e OA
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