HomeMy WebLinkAboutBLDP-19-001059 /x,QCIh5W ("fin)
MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK ,��p
CITY y Ct /*-02.1 -�/tet/!
=L� �I✓Ltt/lc9 �� MA DATE B"-.2-/ - /R�_ PERMIT#
JOBSITE ADDRESS 8'3 "-i 4-Me -r/: C.4.. OWNER'S NAME Lolly
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:74.e PLANS SUBMITTED: YES 0 NO[�}
FIXTURES 1 FLOOR-4 ESM 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 I •
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) _
KITCHEN SINK
I LAVATORY •
ROOF DRAIN
I SHOWER STALL I h - R f -- t I L
SERVICE/MOP SINK I t
!
TOILET i }
URINALIn 23 20,3 ) I
WASHING MACHINE CONNECTION 1 P" b
WATER HEATER ALL TYPES i r
WATER PIPING
OTHER v
I -
iINSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES®"O ❑
IF YOU CHECKED YES,PLEASE INDICATE
�THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY 11: ETOTHER TYPE OF INDEMNITY 0 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 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
kJ I hereby certify that all of the details and information I have submitted or entered regarding this application are tme and accurate to the best of my knowledge
and that all plumbing work and Installations performed under the permit issued for Nis application will be In com 'ance allPertinent n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME/l/t.64-440° ,O, 444 nut- LICENSE# iarr SIGNATURE
MP JP 0 CORPORATION 0# PARTNERSHIP Q# LLC 0#
COMPANY NAME S-i'`Tier /0•L$1 ADDRESS 7 eL s4 rs/cvT 0414 4,k u2
CITY /7/4 u//G1$ STATE ,'i4 ZIP a2-6..yr TEL s tt an a`Zsr
FAX CELL EMAIL 4 T/'/l4B Qc tfe-e "7'A/ALT
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