HomeMy WebLinkAboutBLDP-19-003772 A
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. \ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK {�y
'?%,,t,..,,,,e, CITY j MA DATE 101i l.l- 1 16 1 PERMIT#, ". - ! //i
JOBSITE ADDRESS ( (0, kyc p.iqi1DWNER'S NAMEL al ,. ... C ...-....,...._..
POWNER ADDRESS I.- ........._. u . _. . __... .I TEL -FA:'
TYPE OR OCCUPANCY TYPE COMMERCIAL��I ED TIONAL RESIDENTIAL
PRINT
CLEARLY NEW:I1 RENOVATION:0 REPLACEMENT: . PLANS SUBMITTED: YE S E NOD
FIXTURES 7. FLOOR-4 BSM 1 2 3 I 4 l 5 6 7 8 9 10 I 11 'I 13 14
BATHTUB I .. , . L 7 If IL,,„,,I
CROSS CONNECTION DEVICE 1,._, I, ,.,...1, _.,..1 i '.._ .._..;III I I,.,-,...1 ,..,,_.`[ , '1.,• .,.II,.,,.__,i
DEDICATED SPECIAL WASTE SYSTEM I. _ ,.II "I. „ '1 ,.__. 1.
pl- 'i'i ! � I 1 !
DEDICATED GAS/OIUSAND SYSTEM s P ' ,;I Y r II,., .j
DEDICATED GREASE SYSTEM I 1= ;, I _,
DEDICATED GRAY WATER SYSTEM I Y I-... - - II,.. ITT ,, f, ,,_ e
DEDICATED WATER RECYCLE SYSTEM I, `
DISHWASHER ! , I :.i,.....I i{ __ .. .- I ,I......... :i .. I..._ ,I
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DRINKING FOUNTAIN i I
FOOD DISPOSER .- it II . ll I 11'. _. — i ,
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FLOOR I AREA DRAIN •
INTERCEPTOR(INTERIOR) L..,,_,_ a I II _ J i i _:..,..,.
KITCHEN SINK ' �. , I Tr—.. ;E. _ ,_ II L
LAVATORY
ROOF DRAIN3..
SHOWER STALL II 1 I _._ . I I , T I IJ .1
SERVICE I MOP SINK 4 I. I 11— I II 1I ,.,
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TOILET , ,,° ,, I i II I 1
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URINAL ; ,f , _.. :i--lT r ' II ... ' 1 . _ ,{ ..._. 1 .I .. •
WASHING MACHINE CONNECTION I_..._.__ ' .•,,.III........ I i .._._2, , _.d _ _11I. ,.,,I( ._ , . b...-... .. __...:.II ........I
WATER HEATER ALL TYPES I {, ',I 1 11 , I
WATER PIPING l'� I I -" l I II. 1 ..., I
I 11 . .,C- I [ T ilk ,... I ., II ._:I ..,I
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Q JC Lj
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY a OTHER TYPE OF INDEMNITY n BOND 0
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 D AGENT II
SIGNATURE OF OWNER OR AGENT
l hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best cf my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in mpliance with all Pertinent pros is:or of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _, 1
PLUMBER'S NAME(Craig Bishop _ 'LICENSE# 15101 SIGNATURE
MP ce' JP 0 CORPORATION 0# I,PARTNERSHIPD# —I LLCM
COMPANY NAMES High Efficiency 1 ADDRESS 1378 Route 130
CITY Sandwich 'E STATE Ma 1 ZIP j 02583 I TEL 50B-82573695, ,._
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FAX CELL L EMAIL admin@high-efficiencyllc.com _
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