HomeMy WebLinkAboutBLDP-20-003290 •
MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
• _, =a CITY PO ke--4( MA DATE PERMIT#//-7"` "AC-CV Y2'7'0
JOBSITE ADDRESS 9 /4 sq L.J 0 a . OWNER'S NAME i <
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 11--
PRINT ^/
CLEARLY NEW:El RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO LIB'
FIXTURES 7. FLOOR-+ BSIv1 1 2 3 4 5 6 7 B 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
i LAVATORY 1 t
} , e
ROOF DRAIN
SHOWER STALL
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SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
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WATER HEATER ALL TYPES
WATER PIPING/ `
OTHER kFL)
i INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND ❑
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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 ❑ 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 compliance with all Pertinent provisio e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �
PLUMBER'S ME LICENSE# � SIGNATURE
MP JP❑ CORPORATION/ 0 PARTNERSHIP❑.# LLC❑#
COMPANY NAME —. �c-t �[ ADDRESS ) ,fax 7
CITY 41/ t,egthe/v STATE A4-- ZIP LSO 6(f. TEL.5);(37 Vfo 7 33
FAX k.7ro CELL V6 7 3 EMAIL / S tO tom/ //V_/' c_
• t C,I6 ` Sc — ,
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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