HomeMy WebLinkAboutBLDP-17-001797 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY 56v7L (Yuu7k MA DATE 7)(i�I 016 PERMIT# �p_f7—ev/7f7
JOBSITE ADDRESS q U t`"4- OWNER'S NAME f a Pk �ctGf
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POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMM CIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO
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 I
LAVATORY I -
ROOF DRAIN
SHOWER STALL / _ _
SERVICE/MOP SINK
TOILET I _
URINAL _
WASHING MACHINE CONNECTION _ - -
WATER HEATER ALL TYPES j
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 TH YPE 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 ❑
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 to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be ipct.pliaT nce_wiithh I ertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Y04
PLUMBER'S NAME/ LICEN py °f SIGNATURE
MP❑ JP . CORPORATION El# PARTNERSHIP DILLC CI#
COMPANY NAME E u j 7 04v'''-1 I K Ffej ti-CJ ADDRESS ST 41/C'e-- CUD
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CITY VJ ) ( (6t rh'`0�7k STATE/ 'fr ZIP G)4 7 > TEL
FAX CELL 77`i'` 3Sr3 &'t7( EMAIL t,411,d65sa 4--51y1/4A((•0
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21-
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
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