HomeMy WebLinkAboutBLDP-24-898 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY tit_/t. i'/'1 ) U /"el MA DATE /Q Xi; V ` PERMIT# � P-1-11- 77$
JOBSITE ADDRESt/ /a/enn 3✓-7--ez OWNER'S NAME
OWNER ADDRESS O TEL � v L) FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[v
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:[ PLANS SUBMITTED: YES Ti NO❑
FIXTURES Z 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 RFOIEIVF
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM 16 ZOZ4
DEDICATED WATER RECYCLE SYSTEM OtT
DISHWASHER 1 •
DRINKING FOUNTAIN BU LDIN LILHr\R I M .IVT -
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY -I -
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. YEA NO 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY E; OTHER TYPE OF INDEMNITY 0 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 Chap�r`14�of the General Laws. [, / ,6 / n
PLUMBERS NAME V ' , ► At) ` 't LICENSE# SIGNATURE
MP ❑ JP I CORPORATION❑# PARTNERSHIP❑.# LLC❑# P
COMPANY NAME IA C I P
ADDRESS .3 1 0`in
U8--", �P
CITY I STATE �'"_ , ZIP 0 z' U TEL 7)V ��U /l Z Z
FAX CELL EMAIL ./.1 {!1•�V1 CA r i ® 3 14'
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