HomeMy WebLinkAboutBLDP-17-000185 MASSACHUSETTS UNIFORM APPLICATION FOR A PER IT TO PERFORM PLUMBING WORK
e0 CITY VA./>14. PM Or>l_" 1 NIA DATE / PERMIT# /92")✓-n' ic0
JOBSITE ADDRESS 2 5 G.0c---0"( LGA OWNER'S NAME51-Ale op es
OWNER ADDRESS (,(7 TEL 3--73-/37/ FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES I. 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/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK /
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
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 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POUCY s--- 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 0 AGENT 0
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 provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. g/Q \ ). x `/ n /1
PLUMBER'S NAME LICENSE# / Wa . � LSIGNATURE xn
MP❑ JP[� CORPORATION❑# PARTNERSHIP 0.# / LLC 1:1# P!'d/'
COMPANY NAME Ca rick PT-',1-f- 7Q(czADDRESS f (�/T ' vc" L q rc
CITY c_O (a (/Uq U(�� l� STATVI, ZIP -6 6/ TEL TEL 9?q-r�D 7i ZZ
FAX_ CELL EMAIL
SILON MaIATTI NV7d
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