HomeMy WebLinkAboutBLDP-16-003594 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
=`1 CITY XO1 Y VI^/XC 4 I\ MA DATE PERMIT# /310) -/Ze 9 lI
JOBSITE ADDRESS ,�o L> f l d IOLr oI OWNER'S NAME pYLC V? —&z f
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL D
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES Z FLOOR-+ BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE d l
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER /
DRINKING FOUNTAIN /
FOOD DISPOSER C/ •
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK ,f
LAVATORY f
ROOF DRAIN
SHOWER STALL
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 OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY7''— 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 accurat tq the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in pli e II�gtttinent provi ' f the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# 1 d 10 ( SIGNATURE
MP JP❑ ,,,n p /�C�O ORATIO`N�❑# PARTNE HIP❑.# / Lc❑#
COMPANY NAM /111 t- l l�1/ VI1[/ U/,H- DRESS iJ 5
CITY f vV1.0 M STATE_ ZIP (5- 2 / TEL
FAX CELLO f 9 ,47 cre23'-EMAIL
Nd.c2J
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