HomeMy WebLinkAboutBLDP-19-001856 fj a/A14 N
MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
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j1 ir MA DATE 9 Z7 Ig PERMIT#ikpi%` 06 8 ,
JOBSITE ADDRESS '1'f Aid er err) OWNER'S NAME Re ben an
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL[V
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:Ele PLANS SUBMITTED: YES 0 N0,2
FIXTURES 7 FLOOR-, ESM 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
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
--i LAVATORY •
' ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK •
i TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES V/
WATER PIPING
I OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of M • ,
IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BEL, R E C E a V E
LIABILITY INSURANCE POUCY 12/ OTHER TYPE OF INDEMNITY ❑ BOND 0 SEP 27 2018
OWNER'S INSURANCE WANEit I am aware that the licensee does not have the insurance coverage rem ire by Chapter 142 of the
1 Massachusetts General Laws,and that my signature on this permit application waives this requirement e U(C. •• PA' + .i, d
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It CHECK ONE ONLY: OWNER ■ AGENT 0
SIGNATURE OF OWNER OR AGENT
�I 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 with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ty0c
/PLUMBER'S NAME LICENSE# 1tcTh . SIGNATURE
MP Ii2e JP❑ CORPORATION❑# PARTNERSHIP Q# LLC[fl-#
COMPANY NAME 3k1v) O<canor• Pi /HFeJ ADDRESS / 11 Greta+ wizark id
CITY Cje,��crv:l tC STATEtit__Al ZIP O7--C3Z TEL
FAX CELL77Y 753 83°L EMAIL • In
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