HomeMy WebLinkAboutBLDP-25-191 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY Jo(. .►L VcR�tM.v�l� MA DATE -5-01-3- PERMIT# ?LOP--tr- II(
JOBSITE ADDRESS I' S ft11 L€.. 5 r OWNERS NAME talk14
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POWNER ADDRESS E3 Ri!..ersae 51- @ nAa4 Le AA TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO❑
FIXTURES I. 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
DRINKING FOUNTAIN _
FOOD DISPOSER
FLOOR I AREA DRAIN _
INTERCEPTOR(INTERIOR)
KITCHEN SINK / ,
i LAVATORY / •
• ROOF DRAIN
SHOWER STALL _
SERVICE!MOP SINK _.�Ir[rini,
TOILET
i URINAL o'
WASHING MACHINE CONNECTION / 1P1 . i .
WATER HEATER ALL TYPES
WATER PIPING
OTHER Or u�O1Nv
eY
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESffl—F10❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILJTY INSURANCE POUCY J:4 ' OTHER TYPE OF INDEMNITY 0 BOND 0
OWNE ' NSU ,.' E WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
1 Mas c e eneral Laws,and that my signature on this permit application waives this requirement.
7 CHECK ONE ONLY: OWNER AGENT
SIGNATUR.s OWNER OR AGENT
IV 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 will be in cgvn(I}dno h all P ' pro' on of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. C !�
PLUMBERS NAME LICENSE# pL 37.'A1 SIGNATURE
MP 0 JP Er CORPORATION❑# PARTNERSHIP❑.# LLC 0#
COMPANY NAME RC.ra- P u� M ADDRESS P S`"`} T',�pL 5/-
CITY
f mA: T / STATE/'`C ZIP 0 A,Nc1/ TEL fit/83C 41/C/ .fJ
FAX CELL // // EMAIL /'1 O/un?b�ot�'6)'iii/" t , "�
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No ___ _
THIS APPLICATION SERVES AS THE PERMIT f l n
FEE: $ _ PERMIT # _
PLAN REVIEW NOTES __