HomeMy WebLinkAboutBLDP-16-005559 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
9 CITY 114i:f {,,/ MA DATE `P /Z//6 PERMIT#I' DIZ4'01:51
JOBSITE ADDRESS d C-- S CA,61-5.4.1 A' OWNER'S NAME Feud CO AM
OWNER ADDRESS 2-7 /nA S' /-4,44.141 A TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL. '
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT- PLANS SUBMITTED:YES❑ NO❑
FIXTURES 7 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/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM ,
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
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❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POUCY Lg OTHER TYPE OF INDEMNITY❑ 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❑ 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 ac ate to the est of m owledge•
and that all plumbing work and installations performed under the permit issued for this application will be in mplian II Pe' pro is' of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME 6 4- LICENSE# 1760 7 SIGNATURE
MP❑ JP% CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME Oft *^'� r/`� ADDRESS /47 JZ- S71-
CITY (4/-201- &ton+ STAf /U&- ZIP 07--46`.i.' Tfil 77C /S9�
f°t E E
FAX CELL EMAIL I
APR 12 22016 ,
B ULI L4017M' NI '14?-5.-
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