HomeMy WebLinkAboutBLDP-19-004400 •
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MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
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CITY rc-✓-rvtp vlir• MA DATE VA 3//q PERMIT#gt•
JOBSITE ADDRESS ,2 7 /, 0`a Ae v OWNERS NAME rli/y A_ • 4-/e2e--L S
POWNER ADDRESS c72 7 1'd� J J TEL,So Fr 760 0 /8-0 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:[r PLANS SUBMITTED: YES❑ NO Er-
FIXTURES 7 FLOOR—F 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) v
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL i
SERVICE/MOP SINK
TOILET
I URINAL
. i WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
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INSURANCE COVERAGE: /�
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES E N0 ❑
IF YOU CHECKED YES,PLEASE INDICATE THE E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
l' Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT E
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application ate and accu to the bes f m knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in mplian wi P ' I of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME D 7 / . C/�� LICENSE# /3 G 3 SIGNATURE
MP JP❑ CORPORATION Ef# ofG y 6 G PARTNERSHIP❑•# LLC❑#
COMPANY NAME R/,,, Cl.-h / l�„— br'l /I C ADDRESS 7 ,ar Lor VI ew Yr.:.c.
CITY t/Y S.s- al e K/a r- STATE //4 A ZIP dot 3'7 9 TEL
FAX CELL5rf Y02-G V/7/ EMAIL 1),--p6 70 ®�N..R•/ r_.e,--,
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ _
FEE: $ PERMIT ft
PLAN REVIEW NOTES
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