HomeMy WebLinkAboutBLDP-19-001320 • r
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1: , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
li'+rt� /7�CITY/TOWN 5DJ7I I ViChei )BJ'>i( MA DATE f/so// PERMIT �O
JOBSITEADDRESS I L W'AiS Ave_ OWNER'S NAME River Bart MN/
P OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL D./ 7C .co
PRINT
CLEARLY NEW: ❑ RENOVATION: 0 REPLACEMENT:5" PLANS SUBMITTED: YES 0 NO[✓
FIXTURES 7 FLOOR—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 1
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOIUSAND 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
LAVATORY I
ROOF DRAIN
SHOWER STALL I RECEIVED
SERVICE I MOP SINK
TOILET I
URINAL AUG 30 MB
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES Uli
WATER PIPING I F3BY' -{ll► r— 1 o' t
OTHER
INSURANCE COVERAGE: ,�,.,�
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES L!7 r10 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY L11 OTHER TYPE OF INDEMNITY 0 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 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT
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 in compliance wfrab all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME 1J r 1 4 n N' b10A rel LICENSE# I I '1 77 SIGNATURE
MP 2/ JP 0 CORPORATION[l PARTNERSHIP 0# LLC 0# ,
COMPANY NAME L'41pe 6d Ply,'1ban, f-Wit 1 ADDRESS P 0 ' 61vcx LIzc
CITY SOU n i ?fa'a'if STATE/Z* ZIP a26d6 TEL SW - JSGe -tZzt
FAX CELL EMAIL
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