HomeMy WebLinkAboutBLDP-19-002550 Ai P
S MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
171 iTS
__17--- CITY 1M. V:VW c-t,K MA DATE /U /0as1/2 PERMIT# DP/?1t25 f c3
JOBSITE ADDRESS /CV Alfr OWNER'S NAME //46,,,,.."0”rt-141•%/S`7�
OWNER ADDRESS 94_,q.s- TEL SV 790-C.*rd FAX —
Kt-14
TYPE OR OCCUPANCY TYPE COMMERCIAL Iy EDUCATIONAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW:Er RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO 12—
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 8 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIIJSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY E C E I V E G
ROOF DRAIN
SHOWER STALL
SERVICE f MOP SINK VT 273 20-8
TOILET _
URINAL HUILNCa u 71-'AR MEN
WASHING MACHINE CONNECTION ' " — —WATER HEATER ALL TYPES
WATER PIPING
OTHER '
S-fr gMe✓t / �/Pr"yt_6f )
INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND ❑
OWNER'S INSURANCE WAIVER:lam aware that the licensee does not havq 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 0
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 compliance with ail eminent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r'
/52/I.P4 G7 /6ift�GOA4ilete7
PLUMBER'S NAME
�, LICENSE# g3,?f SIG URL'
MP GY JP❑ CORPORATION IThr PARTNERSHIP❑# LLC❑#
COMPANY NAME -r /6�r r� H , .nz-, ADDRESS !dam /L/f�',V cC*
CITY 4vu epar7' STATE /1161 ZIP OC2CJS TEL SQA-32b'--.78-ria—
FAX SW-79rh6• CELL 5'cYa -S6070d'y EMAIL r4(o4P SasPAim EirA9•r2 P�`'
. , . : . .
Yl�l1-L �L G O
: _
. I _ - ; .