HomeMy WebLinkAboutBLDP-20-004902 020*--0)
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
ITS CITY `j P-f-- 00Tt-k MA DATE Z PERMIT# / P47®'00'9i0A
JOB SITE ADDRESS ii)voEIL5 (,R,\1F OWNER'S NAME C�P
OWNER ADDRESS TEL FAX_
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7 FLOOR--4 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/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY / 3 •
ROOF DRAIN
; SHOWER STALL •
SERVICE/MOP SINK
TOILET Z
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.='Y •
IF YOU CHECKED YES, PLEASE INDICATE THE TYP OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW r/ F'
~LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND ❑ r
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required bythaPfetA32 of the `-f'
Massachusetts General Laws,and that mysignature on this permit application waives this requirement.
9 PP �1 /.
Mr. a
CHECK ONE ONLY: OWNER Nit'
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are ir - .nd accurate t best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co . nc- a jR I ment provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /I
PLUMBER'S NAME 1)E-R£.'L LECLu.-C- LICENSE#ZGOZ2_ SIGNATURE
MP❑ JP CORPORATION❑# PARTNERSHIP 0# LLC❑#
COMPANY NAME ,EP-£K- C.d PLv eA6Z\I C. ADDRESS P O . 80)\ 1 Z.9 PP
CITY >TA LE_ STATE !''IA ZIP a? 4 y TEL s-o a CZ
FAX CELL EMAIL L C..LeLCfbEe_e-LCQ PrIDL•LOCI
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
/0 1 e D /r THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
J/S/ FEE: $ PERMIT#
PLAN REVIEW NOTES