Loading...
HomeMy WebLinkAboutBLDP-23-11981 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 'airy; CITY 1.4uuu MA DATE -� �3 PERMIT#ctL D P • JOBSITE ADDRESS 5;1417 4 � ' OWNER'S NAME f -iA iiirf 47 OWNER ADDRESS TEL F6o-a, -3Ase FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL©� PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 7. FLOOR-I 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/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 T R E C E - E { LAVATORY ti ROOF DRAIN jEC 9 9 SHOWER STALL / • " SERVICE/MOP SINK TOILET % BUILDIN(' JtrHr`fid,r=-fi URINAL -- --1 . WASHING MACHINE CONNECTION 0 WATER HEATER ALL TYPES WATER PIPING { OTHER 1I j INSURANCE COVERAGE: { I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES B—ig0 ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTI INSURANCE POUCY (LI/ OTHER TYPE OF INDEMNITY 0 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 ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT L1.1 I hereby certify that all of the details and information I have submitted or entered regarding this application are tru d 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 a a nen provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# SIGNATURE MP JP❑ CORPORATION/ ❑# PARTNERSHIP LLC 0# COMPANY NAME / ��t.�7f4 7L7l7/ ADDRESS Y rrf te,L///- CITY STATE 417/1 ZIP D L3 3 7 TEL FAX CELL-3-V✓f' "F7k —fY EMAIL C 7/ / )C1) 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