HomeMy WebLinkAboutBLDP-16-005310 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY 14{h'laU441 MA DATE I 1 tLP PERMIT# -/i/1-/67-90 I/O
JOBSITE ADDRESS i 3 BI- ,rock 51-, OWNER'S NAME Ecf tAi ii i J, LAiib
OWNER ADDRESS 25 34 Lrgkyer 1'ec.-C Ot, TEL FAX
Tec.�nc tJ:r y:1;ti 2;t t�
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑—
PRINT �/
CLEARLY NEW:❑ RENOVATION:L�l� REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES-1 FLOOR-4 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/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR 1 AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY 1
ROOF DRAIN
SHOWER STALL 1
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 0'�NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY j2' 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 Pertine provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME ' C i (•,!
LICENSE# Z 2e ( SIGNATURE
MP❑ JP[ y CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME r MA22;1A ?is"1b.tir� ADDRESS � kieN :SAC 1,, 19(.
CITY IVf}t+'C.k STATE 1314 ZIP (1 Leo _.�.
FAX CELL G 17- 2-11-o`t o 3 EMAIL
MAR 9 21116
BUILDING DEPARTME
8y -
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
/'tt a- /"/-e0 4<c ' ' ' ' W/t? . Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES