HomeMy WebLinkAboutBLDP-16-007140 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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JOBSITE ADDRESS 7_ ,? Ire/ /2 E.0( OWNER'S NAME (fe
OWNER ADDRESS — TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0•-""
PRINT
CLEARLY NEW:[RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES <❑
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 H
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY l
ROOF DRAIN
SHOWER STALL l
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
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 NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE F 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 all Pertinent provision of
Massachusetts State Plumbing Code and Chapterap 142 of the General Laws.
PLUMBER'S NAME /co )E"le." S LICENSE#a-3/(Ey SIG ATURE
MP[tom JP❑ `�^CORPPO/RATION / PARTNERSHIP� ❑.# --yLLC❑#
COMPANY NAME D SJ P L't�""(CJ ADDRESS P- '3-X
CITY WN /(� R E D. Y926lv(I TEL ",)" 34 ? 203
FAX CELL EMAIL W ' (6 / G' C�
BUILDING DEPARTNMENT ; / e
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
LPG2/4- fr--& CPC LIP 7/I// ' Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES