HomeMy WebLinkAboutBLDP-17-001499 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY )4MA DATE -! v�, " /6. PERMIT# 17 00/Yf
Y� �' •/U" n C-f- e OWNER'S NAME Ern d e-�Sc'�
JO�SITE ADDRESS �- •
OWNER DRESS- 'k ark)DU +t' TEL FAX
��
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:[[ PLANS SUBMITTED: YES ❑ NO❑
FIXTURES Z 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
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 ' NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYP 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 ap•• .ion are true .•• .- •rate to the best of y knowledge
and that all plumbing work and installations performed under the permit issued for this applicat'. will b- '• •lance w' a f the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �'G� C
/
PLUMBER'S NAME Q2l 6� LICENSE# 901 SIGNATURE MP JP ElCORPORATION❑# PARTNERSHIP❑.# LLC #
❑
COMPANY NAME 1 �7 n(,:f ADDRESS r`�D r[ ��,s ,`
�f 5 TEL (/e_ �l°`L 3.5-6�
CITY Hui! STATE ZIP p d'O �Y
FAX.i� �) T7-5— CELL6, 17 EMAIL de�'14.4;I,P1 p(U`Ylbi„rki G 7cil-ko 'C
ofii
al+
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT it
PLAN REVIEW NOTES