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HomeMy WebLinkAboutBLDP-19-001182 , _ !MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK CITYWQ-S�(0120 �j��oi MA DATE © PERMITS# j®ry}��V/II Lt. 1� JOB SITE ADDRESS J r/1�l�177%74 CIC OWNER'SNAMft/r'2„) { /1I�Ad7il� POWNER ADDRESS S'77b' / TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENT1AL� PRINT CLEARLY NEW 0 RENOVATION REPLACEMENT:0 PLANS SUBMITTED: YES 0 1‘10\1 „ FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 1D 11 12. 13 14 BATHTUB I CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM l DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM • DEDICATED WATER RECYCLE SYSTEM DISHWASHER • DRINKING FOUNTAIN — FDOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY -REGEtfi/ Er. ROOF DRAIN SHOWER STALL • SERVICE I MOP SINK _ i TOILET / _ n7 URINAL . WASHING MACHINE CONNECTION UJILUIIff P 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 h NO 0 IF YOU CHECKED YES,PLEASE INDICATE THETYPE 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 i Massachusetts General Laws,and that my signature on this permit ap?fication waives this requirement 't CHECK ONE ONLY: OWNER ❑ AGENT 0 SIGNATURE OF OWNER OR AGENT 14.1 I hereby certify that all of the details and information I have submitted or entered regarding this application are tru- :nd accurate . e b:- of my knowledge and that all plumbing work and Installations performed under the permit issued for this application will be In co.:•lance with - •. n provision of the Massachusetts State Plumbing Code Chapteg ✓l2 J a-142 of the General Laws. fJ// 4 PLUMBERS NAME/a' 11531 LICENSE#3ni1 . , /SIGNATURE MP❑ JP)S3 1 CORPORATI N❑# PAR 'I RSHIPQQ• LLC❑# COMPANY NAME A& ify h1/4 ektb- 7�y ADDRESSS�7I•of (C.)0x l3) c��/7 C1r?h rtlien/itC�t STATES///)/ ZIP Ca 72 TEL S : 77i ;OL7. > FAX CELL . Iiy1`?-7 EMU bO { f/s2r, pz_b at