HomeMy WebLinkAboutBLDP-23-8535 MASSA�CQH-USETTS UNIFORM
'' L a IN APPLICATION FOR A ERMIT TO PERFORM PLUMBING WORK
1 CITY /////��1 O (/ / MA DATE 2 S PERMIT#B 2-3",545
JOBSITE ADDIa'S b 0 ER'S NAME
P OWNER ADDRESS 5 TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL
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CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES NO 0
FIXTURES 7 FLOOR-4 BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14
BATHTUB ---
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND 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 I MOP SINK -
TOILET - _
URINAL R F C FIN ti D
WASHING MACHINE CONNECTION r--
WATER HEATER ALL TYPES z
WATER PIPING / 4 Mir
OTHER r 1�, j-ft WIN ,
6o"T �i!(lUvf3JTfC )-- Iuir DING i>e,'/AHrtArNi
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INSURANCE COVERAGE:
I have a current liability insurance policy or its su al equivalent which meets the requirements of MGL Ch.142. YES - NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY OTHER TYPE OF INDEMNITY ❑ BOND 0
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
LI I hereby certify that all of the details and information I have submitted or entered regarding this application are true an 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 complia with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. (.1
PLUMBER'S AME N LICENSE# f<j Lf" /.� SIGNATURE
MP L] JP pQ CORPORA ION D# PARTNERSHIP❑.# LLC❑#
COMPANY N E14 t/►-g2T 1 !/ V ADDRESS ]_
CITY Y V TP STATE i zZIP 0 0 / ,fit TEL 1 /
FAX CEQLO 3h0 `1 / )EMAI r V i D V
/rya ,a0'\
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
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