HomeMy WebLinkAboutBLDP-17-000286 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY 60• Y4 ,/b0c.1TH 1 MA DATE !�`r v PERMIT# J� 1'��/7—
JOBSITE ADDRESS 1 vl �O i CA v' c'� D OWNERS NAME kA7ye fiV E CfSC
POWNER ADDRESS 4-16 SO.1.4()A}'6' C" TEL LIO SJ a`fZ3 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL .
PRINT
CLEARLY NEW:❑ RENOVATION: r/4, REPLACEMENT:❑ PLANS SUBMITTED: YES F!S 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 {
DRINKING FOUNTAIN _ _
FOOD DISPOSER
FLOOR/AREA DRAIN _
INTERCEPTOR(INTERIOR)
KITCHEN SINK 1
'VATORY
%ROOF DRAIN
SHOWER STALL
1
SERVICE/MOP SINK
TOILET J
RINAL
ASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
N, WATER PIPING _
I OTHER
INSURANCE COVERAGE:
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 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 ❑
SIGNATURE OF OWNER OR AGENT
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 Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# 2(...,?9, IGNATURE
MP❑ Jligt.. CORPORATION❑ / PARTNERSHIP❑.# LLC❑#
COMPANY NAME 41 PC�?2 AY Pc U' f'VG*-W(- W ADDRESS /0 )C R 0-&V C. 4 C((--7--
1lv,,�
C11c R
AM i 1 STATE 1M ZIP 0 2 6`i 9 TEL V0 7 I J^'50 k
FM CELLS 6$ Cf/ 7 7 EMAIL oJPriuin'J!/1gc+- �►?ciliA�Y e `�,4� i€0, Co'''‘
JUL_ 19 2016 e J J
BUILDING DEPARTMT
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