HomeMy WebLinkAboutBLDP-16-002563 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
=r1=p CITY y,/l7/LIliuf7.4/ MA DATE PERMIT# t'ap-4'-0096 3
JOBSITE ADDRESS3G G[c.(/.147if4//La_0 - r( OWNER'S NAME EL/L///PG %
OWNER ADDRESS 710
- TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL El RESIDENTIAL LI—
PRINT
CLEARLY NEW:❑ RENOVATION:El REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO 111__—
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
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET _
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES 1
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 E4-1 O ❑
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 El
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 corn�n a/with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 7 // `I )YG—
PLUMBER'S NAME /t(CA LICENSE#/r ls" SIGNATURE
MP Er JP El CORPORATION El# PARTNERSHIP❑.# LLC❑#
COMPANY NAME /'I 77 tJ "f/;4- ADDRESS 7 ,4 , J /T /'t C;2i
CITY l744 6-6(Glf STATE/Lf/9- ZIP -G 4'S� TEL
FAX CELL 3 7 2-S7 7 EMAIL
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
7