HomeMy WebLinkAboutBLDP-20-001977 r
1. 71 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
_- CITY Yf-'7eif.[p u MA DATE fobj 7 PERMIT# 046-00 f i77
JOBSITE ADDRESS /pl-e Al j 9 el OWNER'S NAME M 1 9
P OWNER ADDRESS _ TEL FAX
FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 111-7.
PRINT
CLEARLY NEW:❑ RENOVATION:. REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO L!
FIXTURES 7 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
LAVATORY /
ROOF DRAIN
SHOWER STALL / -
/D
SERVICE I MOP SINK J
TOILET /
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. YES NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYP COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ' '
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND337Z 40i0 67)
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.
i
,, CHECK ONE ONLY: OWNER d 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 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 co pliance with all Peril nt pro jsio
Massachusetts State Plu��ing Code and hapter 142 the General Laws.
PLUMBER'S NAME jj,,JJ�� 6/l/ e 0 LICENSE# lc?8 7 IGNATURE
MP L]J/ 1P El CORPORATION PARTNERSHIP❑.# LLC El#
COMPANY NAME 4- -Z) D S'1/4 if LG ADDRESS ,0 409e -7(-12
CITY 'J •A .A-, STATE ZIP p( $' TEL
FAX—362 CELL ��� ) 2Z5' EMAIL 14A An a ( c
Al-
.
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT ft /5q
PLAN REVIEW NOTES 1 /9G�9-r �Lv�,
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