HomeMy WebLinkAboutBLDP-16-006601 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
Z11741-_ �- CITY a i' L.- MA DATE !S` )// PERMIT# e4i 4 /��bef(
JOBSITE ADDRESS T 9 �'�' ' �!� S OWNER'S NAME 41 9 J-_ /14G/H
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ 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 _
DEDICATED WATER RECYCLE SYSTEM _ _
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK • o
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. YE NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE E 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 El
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are t nd accurate to the st of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be- pli nce with all Pe ' provisio of the
Massachusetts State Plumbing Code and C pter1y of the General Laws.
PLUMBER'S NAME a LICENSE# j-33 d SIGNATURE
MP❑ JP "7411
CORPORATION El# PARTNERSHIP El# LLC❑#
COMPANY NAME /•-lle ADDRESS (0/ Q e RC/1
art-v� G l � /
CITY STATE—ZIP ( `f 5 TEL � �"�-4 � G V/7
FAX CELL EMAIL
ROUGH PLUMBING INSPECTION NOT S BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Pill- M'69 a'YJ-f/ o 7 i7 Yes No
THIS APPLICATION SERVES I 10 AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES