HomeMy WebLinkAboutBLDP-19-001628 $ . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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LCITY VArYln o G ttn MA DATE 9 " I i - I g PERMR# e g`00/6021
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JOB Sff E ADDRESS I S y \i,I2. G-61 c OWNER'S NAME Va f M OWL` 1„
POWNER ADDRESS C G 11.YJ TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL u EDUCATIONAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:Er PLANS SUBMITTED: YES 0 NO 0
FIXTURES I. FLOOR-, BMA 1 2 3 4 5 6 7 B 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
I LAVATORY .
, ROOF DRAIN
I SHOWER STALL •
! SERVICE/MOP SINK
I TOILET
URINAL IR ' Ci bI `/ F , L
WASHING MACHINE CONNECTION — -
WATER HEATER ALL TYPES
WATER PIPING b ' 11 218
OTHER`
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1J €-& 5 -e-le- Puars f 4 :UIL 1ING DEP RTMENT I
INSURANCE COVERAGE: I/
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES I/ NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [ OTHER TYPEOF 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 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT
Lu 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 appfcation Moll be In comp ncR with all P nent provision of the
Massachusetts State Plumbing- Code and Chapter 142 of the General Laws. G / / ' n^
PLUMBER'S NAME ''re t r fly, LICENSE# I� 2.1 ` / (SSIIGNAt SIGNATURE
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MP Er JP❑ ^ pCORPORATION 0# PARTNERSHIP # LLC 0 it
COMPANY NAME ..-1(kW. J / 7� k WAI 1 IN{/r� ADDRESS Li 7 4�/ t D n sl 6 L C-vu co.. Q c./ 1
CITY Fait 10 000th STATE "t(. ZIP 172. 4Ca Y TEL 50 -2373CSet(
FAX CELL Cin tb1 2._ EMAIL
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