HomeMy WebLinkAboutBLDP-25-80 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
i CITY f&/'��L(%�ti�CMA DATE Z-I L/ cPERMT8L.oP. c- �G
JOBSITE ADDRESS l(L, (J ( C 7/t 1'OWNER'S NAME /C la z_
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYP COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL[1/
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
FIXTURES T 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)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE 1 MOP SINK
TOILET; WATER HEATER ALL TYPES riga
WATER PIPING
1
, OTHER
INSURANCE COVERAGE:
{ I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Y NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE�,'P"E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POLICY 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❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are tru 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 in com ante with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAMAti moyr /VV CENSE# 15-K; SIGNATURE
MP Jp ` CORPORATION # PARTNERSHIP❑# LLC 0#
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COMPANY NAME ADDRESS
CITY Ym 4""/ram /'vT� STATE l"'t ZIP Z‘ 2/ TE65-o 366 3 V3
FAX CELL EMAI 00
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