HomeMy WebLinkAboutBLDP-18-007339 fc
t ,f tASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
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ttre " CIN VA-Ptp ei MA DATE ib-7/p PERMIT#/�I-4I1'/� /
JOB SITE ADDRESS 02T CA-0 r c L. ir OWNER'S NAME Le O Oy
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENT-VIE
PRINT
CLEARLY NEW:0 RENOVATION:'; REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 7 3 9 10 11 12 13 14
BATHTUB 1
CROSS CONNECTION DEVICE _
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/01L/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM _R-E q E h/ t ►+
DEDICATED WATER RECYCLE SYSTEM1
DISHWASHER I 2 I
DRINKING FOUNTAIN r I `
FOOD DISPOSER UL . I
FLOOR I AREA DRAIN I
By
INTERCEPTOR(INTERIOR)
KITCHEN SINK 1
I LAVATORY 3., I •
• ROOF DRAIN
SHOWER STALL I
SERVICE I MOP SINK _
TOILET I 1
URINAL
WASHING MACHINE CONNECTION I _
WATER HEATER ALL TYPES
WATER PIPING
OTHER 43o,Ie.c Br-okrIn.i I
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ty NO 0
IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY jlc OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
i Massachusetts General Laws,and that my signature on this permit application waives this requirement
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 thebest of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be In co 'ce with all Pedirr� ro ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME LICENSE# /0320-. S TU E
MP ti6 JP 0 CORPORATION 0# PARTNERSHIP❑.# LLC❑#
COMPANY NAME 't ry cflq CH*CkS ADDRESS )'3 7 r re Ft-r.0 S T
CITY F , 0 as) STATE n'W ZIP Oa-6 V/ TEL COTa i v— n6/
FAX CELL EMAIL
Leif
?,*-e/pi Iry 7 1(49
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