HomeMy WebLinkAboutBLDP-17-004095 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY �Cl�f"7� e- MA DATE Z — /0 ` / , PERMIT#W�7 00 N[
AP
JOBSITE ADDRESS / AC'_ cr'tG.^/ S 'c1. 7/e/ OWNER'S NAME )C;- .r -Z O
OWNER ADDRESS i.5—e-'97-77Zei, , /7 ---C7/`n7/e/ TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCA ( NAL ❑ 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 -FEB 4- 4 20
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER ��
DRINKING FOUNTAIN �1Q ti�+i G.Ci 3
FOOD DISPOSER T
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) _
KITCHEN SINK
LAVATORY
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 L� NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ OTHER TYPE OF INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER:I am e that the licensee does not have the insurance coverage required by Chapter 142 of the
j` Massachu :tts Gene aws, a • nature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER AGENT
SIGNATURE OF OWNER OR AGENT
\`l 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 w ertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,its
PLUMBER'S NAME - LICENSE#j:3T h4J SIGNATURE✓
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MP❑ JP ❑ CORPORATION ❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME /7f/'t.0 Sicetc5
7 ADDRESS 39 i1 V&A.) L L
CITY STATE An ZIP 0 j TEL ll ��11
FAX CELL l,5�$34y �p4/€ EMAIL 4rjti S0jar14 . l
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