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HomeMy WebLinkAboutBLDP-25-633 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK i.31-.. � `s,-s ;_ z '`►j=;� MAP PARCEL DATE � � 2� PERMIT# >�/.) P- 2 - 4'.:53+ JOBSITE ADDRESS i 5 7 OWNER'S NAME • 9 S4nd�c44c , f f / ffr / �� Ir POWNER ADDRESS j 1 1 TEL 'FAX TYPE OR OCCUPANCY TYPE x�COME IAL Q EDUCATIONAL © --/tesiDENT - PRINT CLEARLY NEW:El RENOVATION:® REPLACEMENT:Q PLANS SUBMITTED: YES© NO( ' FIXTURES 7 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I • — CROSS CONNECTION DEVICE 't' l ' DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM , DEDICATED GREASE SYSTEM I 1 DEDICATED GRAY WATER SYSTEM l f I i,a 1 DEDICATED WATER RECYCLE SYSTEM DISHWASHER _. _ _.. DRINKING FOUNTAIN I ;, ' I i FOOD DISPOSER ' FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK I LAVATORY T .I Ala T , . _, _ - M .r 2 V. 1 Si lrP_ Y. I ROOF DRAIN . r • . . • . .. r ♦ __ r -taw SHOWER STALL SERVICE/MOP SINK - TOILET URINAL WASHING MACHINE CONNECTION 1111111111111111111111111111 WATER HEATER ALL TYPES WATER PIPING ;( 4 '_: . s_- ,,,, r .Are. ` i OTHER i I l INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES JJ NO Li 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 0 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 Chapter 142 of the General Laws. _ PLUMBER'S NAME 4A cj,� ; f 1 tom(/ i LICENSE#U �,^' 1 I SIGNATURE VA 5 MP® JP 0 CORPORATION©# PARTNERSHIP©#� LLCQ# Dc r�P i COMPANY NAME WI ( ckLP p ILi ADDRESS .-ii N c/ -4-(1 i I . 1 I CITY . .\Al 5 . 'STATE ZIP TEL v/ TEL )7 Y `6-(u cll Z 2 FAX I CELL j EMAIL �,� L1`'0.��'I�:.r.1,1 t c, -P v - I i ' C DM ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: E PERMIT# PLAN REVIEW NOTES