HomeMy WebLinkAboutBLDP-17-004063 (Gg¢sT /0 4 /55
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
• ="— CITY • MA DATE t IC,(/7 PERMIT# / -i9 17-� �
F— ram) OG2/2i r1 ' Z--41 OWNER'S NAME �1 ,'�
JOBSITE ADDRESS
OWNER ADDRESS TEL TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIALfl�'
PRINT ,�,
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES Ll, N0❑
FIXTURES T 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 FEB 1 0 ?O
DISHWASHER
DRINKING FOUNTAIN fY
FOOD DISPOSER Q U0X �
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK / y
LAVATORY •
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING j
OTHE
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 V OTHER TYPE OF INDEMNITY ❑ BOND ❑
t 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 all Pertinent provision of
/lMassachusetts State Plumbing Code and Chapter 142 of the General Laws. 14liL,60 /Al
cPLUMBER'S NAME 6( 1I /Jv6'- LICENSE# [/( 0 2 SIGNATUREE
MP JP ❑ CO PORATION [ PARTNERSHIP❑.# LLC❑#
COMPANY NAME �7 -1J J, ✓ /LC b ADDRESS pc /36 -7°
CITY bu W O//,�- STATE OM ZIP O(O�jj TEL ,30 / 7
FAX 3 g 3 CELL ��� -335Y EMAIL De/3I • / ) c C
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
f // FEE: $ PERMIT#
PLAN REVIEW NOTES