HomeMy WebLinkAboutBLDP-16-005089 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
=`I : CITY.....,::::.,�.:y KW eq 7� MA DATE 3 `��b � ' �o PERMIT# LIT lb / J�
JOBSITE ADDRESS/ 00tP Or 1L-Q_ c7� OWNER'S NAME"4 kk"
POWNER ADDRESS / a lz/ k '`f OL1 hTEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL� EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:� PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR-4 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
- - 7
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
T
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 El
IF YOU CHECKED YES,PLEASE INDICATE THE TY F COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND El
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 t e and acc to to the st of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be i co lian II Perti t provis n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S AME i`oh ''( i -om i1 P 1j LICENSE# /1.N I NATURE
MP JP❑ CORPORATION ❑# PARTNERSHIP❑-#
COMPANY NAME(4 se Ll/((J." ),- VooVIJ^—e ADDRESS / ) 'C d�l 1/-1 P I/ '( 17
CITY /( g�Lf a.(� STATEe k7, ZIP (22 Yet TELS 0/ 7/ 40 3
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