HomeMy WebLinkAboutBLDP-25-642 � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY ‘1 At1 OUTR MA DATE g'Z$•Z5 PERMIT fR 42:4°ogS r 6�—
, JOBSITE ADDRESS Z 1 &tt ( .) La,L,j OWNER'S NAME 6 3 fiki.E*CrT-
POWNER ADDRESS TEL FAX__________
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL❑ RESIDENTIAL'
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENTI PLANS SUBMITTED:YES❑ NOfiS
FIXTURES-1, FLOOR-, 6SM 1 2 3 4 5 6 7 6 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(INTERIORL
KITCHEN SINK
LAVATORY •
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK r—
TOILET 4 ` -
URINAL .
WASHING MACHINE CONNECTION _bU6 2 8
WATER HEATER ALL TYPES -
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WATER PIPING -
OTHER � �N1L -
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES'' NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POLICY 1:;6,, OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
1 Massachusetts General Laws,and that my signature on this permit application waives this requirement.
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER❑ AGENT❑
L I 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' mpliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. •
PLUMBER'S NAME OR:att. St.tTN LICENSE# t7Zcsi. SIGNATURE
MP 541 JP❑ CORPORATION❑# PARTNERSHIP a# LLC❑#
COMPANY NAME D P(.0 M�T JJ C3- ADDRESS ---7`1 EAST OST( V TLC 6 1219
CITY (5 -CLO-V�<L- STATE Nll4- ZIP 62C355 TEL 57 YSZO `1(o%c
FAX CELL EMAIL OTS?1 `QDKSFEVP*LQGP'qtC-L-L(4\
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
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