HomeMy WebLinkAboutBLDP-18 ? MASSACHUSETTS UNIFORh .r'LICATION FORA PERMIT O PERFORM PLUMBING WORK
PERMIT#__L CITY V MA DATE y /�" t�
JOB SITE ADDRESS /7 CC('-A, x-/ ' N ER'S NAME
OWNER ADDRESS /1—tli TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:E RENOVATION: REPLACEMENT:c17---- PLANS SUBMI I I ED: YES❑ NO❑
FIXTURES Z FLOOR- BSIv1 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 1 AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL C-16
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 sntial equivalent which meets the requirements of MGL Ch.142. YES NO ❑
1 IF YOU CHECKED YES, PLEASE INDICATE TH PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ OTHER TYPE OF INDEMNITY ❑ BOND ❑
1 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 a rate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complian all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# /�C / SIGNATURE
MP LjY JP CORPORATION N (p
� ❑# PARTNERSHIP❑# LLC❑#
COMPANY NNAME /1-066g P `I ADDRESS 25—AUr I ) /e-
ib
CITY J /zvo v`-k( STATE ZIP v2C7g TEL`5 v P O
FAX CELL
EMAIL
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