HomeMy WebLinkAboutBLDP-20-000766 I1C)
,� MASSACHUSETTS UNIFORM APPLICATION FO A PERMIT TO PERFORM PLUMBING WORK
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CITY ✓ r' G MA DATE % a Di 9 PERMIT##01,JP/D YSC07(p6
JOB RE ADDRESS I V/ �tQ die 6kya 6(1RCOO OWNER'S NAME_Clock A 12 1
POWNER ADDRESS / 1u TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIa
PRINT ������
CLEARLY NEW:❑ RENOVATIONA REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO-tit
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/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM _
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER I • _ —
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK I'
LAVATORY
ROOF DRAIN
SHOWER STALL '
SERVICE/MOP SINK _
TOILET
URINAL
. i WASHING MACHINE CONNECTION ' _
WATER HEATER ALL TYPES
WATER PIPING I
OTHER
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I INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YE ' NO 0
IF YOU CHECKED YES,PI FocE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY' 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.
r CHECK ONE ONLY: OWNER❑ AGENT❑
SIGNATURE OF OWNER OR AGENT
LJ I hereby certify that all of the details and information I have submitted or entered regarding this application are true d accurate to of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be In compt ce ' all P ' provision of the
Massachusetts StatePlumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME4 o>^ne J USSI M. LICENSE#3)q 7( . IGNATURE
MP❑ JP 0 CORPORATION 0# PARTNERSIIT 1C E f V E lb_l#
COMPANY NAME ADDRESS
CITY STATE ZIP AUG 0 9,-2_019
FAX CELL EMAIL BUILDITME T /
ny
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
Q ay' THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
6( ( FEE: $ PERMIT #
/NO- n-0 07/:7 L PLAN REVIEW NOTES
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