HomeMy WebLinkAboutBLDP-17-005735 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
Wi; 1
CITY_YcJrM o4 h MA DATE 574 7 PERMIT# /91--i9i'—,7-Oe) *4-'
JOBSITE ADDRESS -/S L 00KOtit Rd OWNERS NAME 73d . L. ✓N� 5 73
OWNER ADDRESS I i ' TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: ❑ RENOVATION: ® REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES T FLOOR--ti 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
T _
FOOD DISPOSER
FLOOR/AREA DRAIN _
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY c
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 M- NO 0
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 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 Pertinent provision of the
Massachusetts State Plumbing Code and Chapternn 142 of the General Laws.
PLUMBERS NAME CI,.f'r S G h& LICENSE# /31 7 -✓SIGNATURE
MP JP❑ CORPORATION❑# PARTNERSHIP 0# n LLC❑#
COMPANY NAME /14SfcY toC1C ✓M�, ADDRESS P.o • 80A t7 ?6
CITY �JNieee- STATE M�1/� ZIP 046 TEL TEL So 8 Li hi- d.8do
P
FAX CELL /1 I' 11 EMAIL C r` t UrcS6oJS
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