HomeMy WebLinkAboutBLDP-24-127 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
_. 10 CITY AR A-�D�'ty^ MA DATE -•I' ! PERMIT#&bP'a`-/2
JOBSITE ADDRESS OWNER'S NAME
OWNER ADDRESS TEL ,FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL LrJ
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:" PLANS SUBMITTED:YES 0 NO❑
FIXTURES 1 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 GASIOIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR) :Q F F 11/
KITCHEN SINK
LAVATORY
ROOF DRAIN 1 tE84 20
SHOWER STALL
SERVICE I MOP SINK -ulLoivcGDLPARTMENT
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 INDICATEE THEHE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POUCY Ly 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 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this applicati re t and ac to to the best of my knowledge
and that all plumbing work and installations performed under the permit Issued for this application wi in comp once ' all P sion of the
Massachusetts State Plumbing Code and Chapter 142 of the General laws.
PLUMBER'S NAME UCENSE# II.LefR SIGNATURE
MP[1 JP 0 CORPORATION /a#.155.0 PARTNERSHIP 0# LLC 0#
COMPANY NAME'D �'p r��r s-�8 p E4 I, -ADDRESS '0,V rpyC Cs)
CITY 9 wn ' 9 STATEI'^-40a ZIP c::=•a-(o&t 1 1 'TEL 5cP- ^�Z7
FAX CELL X P a l,n'S S EMAIL Cir Q+5 C� 0 hX
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