HomeMy WebLinkAboutBLDP-19-005201 #6 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY S. 414vt OUT t b MA DATE 3_ °3,I PERMIT# ) /p � �/
JOBSITE ADDRESS S4 5 1 # 2 "4 Co, OWNER'S NAME 130 L326 EA
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 2 EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:(/ PLANS SUBMITTED: YES❑ NO❑
FIXTURES Ti. 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/OILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR 1 AREA DRAIN E. r E, 1 V 0)
INTERCEPTOR(INTERIOR)
KITCHEN SINK I w {�
LAVATORY - MAK Yj3
ROOF DRAIN
SHOWER STALL QUii O►NG ptARtMCNT •
SERVICE/MOP SINK av
TOILET
URINAL
. i WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING 2.
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 TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY le 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
t' I hereby certify that all of the details and information I have submitted or entered regarding this application , -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 • pliance all P ent provision of the
Massachusetts State Plumbing Code and Chaptera� 142 of the General Laws. 4
AN
PLUMBER'S NAME i d.�✓(S e--►A l!KS LICENSE# ( ( fig Z- 'V de SIGNATURE
MP V.
JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME JCNIS 3' Cy`P�,ri1/vS ADDRESS p, 6 • 6 on 1 3
CITY N STATE P(411 ZIP a 2-4;1 TEL 7 7 a .53`b 7r 4`1(
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FAX CELL ,,?7'3 -b q Li EMAIL dC'-e-1✓l rli.s
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY
FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT if
PLAN REVIEW NOTES
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