BLDP-19-001551 • ( (,I
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MASSACHUSETTS UNIFORM APPLICATION FOR AA PERMIT TO PERFORM PLUMBINGWORK
LoolCITY fr,9410U?I� ✓ , MA DATE Q/ I y�/I/ PERMIT# *03.19-4°/(67 i
JOBSITEADDRESS `l9 -7'tUtf&C' A ! OWNER'S NAME /`?LlysjiG• ArblvG/�j '�
POWNER ADDRESS TEL /FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL EJ
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:[J PLANS SUBMITTED: YES 0 NO I;
FIXTURES 1 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/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM _
DEDICATED WATER RECYCLE SYSTEM _ ' • E 0
DISHWASHER • I R '
DRINKING FOUNTAIN 1II
FOOD DISPOSER I , 1 ,)
FLOOR I AREA DRAIN Ij j
INTERCEPTOR(IN I tKIOR) ME
KRONEN SINK I bineirl.
I
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LAVATORY •
ROOF DRAIN
SHOWER STALL
! SERVICE/MOP SINK
i TOILET
URINAL
i WASHING MACHINE CONNECTION
WATER HEATERTYPE
WATER PIPING a,/ ivei /
OTLLLL
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Z NO 0
IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LABILITY INSURANCE POLICY Z OTHERTYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware thatthe 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
et CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
1-11 I hereby certify that all of the details and information I have submitted or entered regarding this application are true an rate to the best of my knowledge
and that all plumbing work and Installations performed under the permit issued for this application will be In corn is ' all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME 6 -Q410.5 LICENSE# O G Zu
fra. !SIIGNNA,TTURE /�
MP[21 JP El CORPORATION❑# PARTNERSHIP 01 (IC! i#cS,/
COMPANY NAM/ ///A ft 14.6 /a /ADDRESS a' ' .4‘�
CITY LU! Yh't119141/ STATEIIt ZIP 920"2; TEL 40'/��0 <2 '
FAX CELL EMAIL G ' Je2d/ (O, Za/14 i/Me
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