HomeMy WebLinkAboutBLDP-25-776 S pr en-121 ��
MAS ACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
51v CITY 1 MA DATE CO liOJZ.. PERMIT# )/' /i7
, x ZJOBSITE ADDRESS WNER'S NAMEMAN/ PUC-
POWNER ADDRESS TE6556 3 $76v FAX
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TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW: RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 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 r
no , ,
DEDICATED GRAY WATER SYSTEM V
DEDICATED WATER RECYCLE SYSTEM _
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN _
INTERCEPTOR(INTERIOR) T
_ KITCHEN SINK _ _
LAVATORY - _ _
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL 1.
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING _
OTHER _
10 � w .
_ . - _
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 127NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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
1 Massachusetts General Laws,and that my signature on this permit application waives this requirement.
T
CHECK ONE ONLY: OWNER ❑ AGENT 0
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SIGNATURE OF OWNER OR AGENT
k.I I hereby certify that all of the details and information I have submitted or entered regarding this application are true and a urate 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 w h II Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER'S j'oil, Df A
!W nA 6,,jv0„JC LICENSE# /51/9 6 SIGNATURE
MP JP .El CORPORATION❑# PARTNERSHIP❑.# LLC 0#
COMPANY NAM 11�6,7-12-i P i /If ADDRESS 75tAITaiJY /
CITY `j I1i1 D -rq STATE Pliirf. ZIP d Z 7 T LO ) 36 qq2
FAX CELL EMAlheAdi 1�'I,' 4a/ O u L� rOt I
- (00_ covey-, 41 i (
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