HomeMy WebLinkAboutBLDP-19-001552 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK .
E:4V y C(iY` ,kM.ud19 L P'1. - . MA DATE. :PERMIT#/ /,P-/9`6d 1531'2
JOBSREADDRESS 5y G}trvt44. • OWNER'S NAME 43 ESS WEiAl_.._.
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OWNER ADDRESS .. . TEL
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TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL; ✓
PRINT •
CLEARLY NEW:; ' RENOVATION:_: REPLACEMENT:7,:--- PLANS SUBMITTED: YES. NO
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB — - .
CROSS CONNECTION DEVICE 1 _ - - _
DEDICATED SPECIAL WASTE SYSTEM -
- .DEDICATED GAS/OIUSAND SYSTEM . -
DEDICATED GREASE SYSTEM - • . ` - . .
DEDICATED GRAY WATER SYSTEM '
DEDICATED WATER RECYCLE SYSTEM ' . "- '
DISHWASHER . -
DRINKINGFOUNTAIN _ -
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 At MGL Ch.142. YES 71, NO ' -
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW _. .
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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 J ..
SIGNATURE OF OWNER OR AGENT '
I hereby cerdy that all of the details and ktfonnation I have submitted or entered regarding this application are two and accurate to the best of my lino/ledge
and that all plumbing work and Installations performed muter the permit Issued for this application wII be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. CM
1_ . L�pSIya
PLUMBER'S NAME•Mark Couto LICENSE# 15856 -. SIGNATURE
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MP.• JP . • CORPORATION-+- P
# 3408 PARTNERSHIP ✓ — 'LLC' #
COMPANY NAME Mark Couto Plb&Htg Inc. ADDRESS 1103 Lake Shore Dr •
CITY BrewsterSTATE. MA ZIP 02631 ' TEL 508-965-2145:- •• '
FAX 50(1896 2577 'CELL' EMAIL Iuiadgcou :-. ._
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BUILDING DEPq H-fr�jENT
By:
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