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HomeMy WebLinkAboutBLDP-18-003835 , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK tvi _'•`_ -� CITY/TOWN MA DATE //E( PERMIT#/ /71,'OU �� JOBSITE ADDRESS )C/ C-4- i /c wrV7 OWNER'S NAME OWNER ADDRESS 2 G Lam,w�,,r ,�,?�rd E TEL.52i ,7 tom( FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: E PLANS SUBMITTED: YES❑ NO❑ 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/OIUSAND 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 Idle W+++:��)___J SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES / l 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 VNO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY © OTHER TYPE OF INDEMNITY ❑ BOND ❑ 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 tru nd accurate to theest of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co I. n all Pertirreprovision of the Massachusetts State Plumbing Code a�nhapt/er 142 of the General Laws. PLUMBER'S NAME Eq / / 1//4 LICENSE# //3 2 2 SIGNATURE MP�P❑ 9RPORATIONME# PARTNERSHIP❑# LLC❑# COMPANY NAME /// °///,/ ADDRESS . `. g ?6/7 CITY �C C lJ S T UZ STATE /1M41 ZIP D Z 6 3 / TEL f t,o Z.-3 7 .S 7Z 7 FAX CELL EMAIL