HomeMy WebLinkAboutBLDP-24-170 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
—I-1 �
• =LI=-0 CIT1l��(�t���u l T l MA DATE �/ I (.0 Z PERMIT# OLD P-24- lid
•
JOBSITE ADDRESS I rJ S(DUCT k W I S1 OR OWNERS NAME
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 0�
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:0 PLANS SUBMITTED:YES 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/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY Z •
ROOF DRAIN 1
SHOWER STALL
SERVICE/MOP SINK ( '
TOILET
- 1E01 s 2024
WASHING MACHINE CONNECTION I _
WATER HEATER ALL TYPES 1 HULUIN,oULYAr{IMf.NI
WATER PIPING s
OTHER
I _
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 TH TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY INSURANCE POUCY 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
J 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:t I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and Installations performed under the permit issued for this application I be in cernpaence'alA ll Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBE 'S NAME LICENSE# L I SIGNATURE
MP JP 0 CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME-7 LA J14-S P M.61NG , ' ADDRESS 21 -C�I1;ATC-E C_7L-0
CITY C 1�YN DU�C1 1 STATE MTt ZIP 0 2-3( O TEL '
FAX CELL1%55gC oci(A EMAIL TUK7K-S\P U/VM,a1N6®�/MML,C
//U,DO
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT n 1 I
FEE: $ PERMIT if
PLAN REVIEW NOTES