HomeMy WebLinkAboutBLDP-19-001061 MASSACHUSETTSHUNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBIN/GG WORK
-z—.=21---= CITY GJts /0.t MO.� fMA DATE 42-12411( PERMIT#*D/' /Y"'OQ/66(
JOBSITEADDRESS (o2 bna•S Qo--t OWNER'S NAME £✓)k('el Josg1,
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL K
PRINT
/ CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:M= PLANS SUBMITTED: YES 0 NO❑
) FIXTURES 7 FLOOR-. BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14
BATHTUB I _
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM •
DEDICATED WATER RECYCLE SYSTEM _
DISHWASHER I •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
__ KITCHEN SINK I RECEIVE-0
I LAVATORY I I • _
j
ROOF DRAIN
I SHOWER STALL 1 AUG 2 l 7 I H I
! SERVICE/MOP SINK
ITOILET I e 1}l
URINAL i
i WASHING MACHINE CONNECTION
i WATER HEATER ALL TYPES
WATER PIPING
I OTHER
I
I INSURANCE COVERAGE:
I I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO 0
IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LLABIUTYINSURANCE POUCYAI OTHER TYPE OF INDEMNITY ❑ 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 requiremenL
CHECK ONE ONLY: OWNER 0 AGENT 0
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 application will be in compliance wi all P rtinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Sea.., Han a-n LICENSE# I52-22 . SIGNATURE
MIPLIN JP 0 CORPORATION❑# PARTNERSHIP co LLC❑4
COMPANY NAME VlanC Aan P4II ADDRESS Po &a,c &Et-
CITY (en f•I`JC I(J_. STATE N ZIP 012682_ TEL 174438--Ica-iCP
FAX CELL EMAIL \anrr pt0^r/6/,6eJ�clM/f�tft•47/✓t
ern,
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