HomeMy WebLinkAboutBLDP-19-002807 MASSACHUSETTS\ UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
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CITY VV 7'AWM°UTh MA DATE 7f/s/1Q PERMIT#frDm -COS07
JOB SITE ADDRESS `n ? CCken.O ST OWNER'S NAME UeAfkel" mirk*
OWNER ADDRESS 11 e Laky/A.1d 2a `-1Y-"L~'TEELfrOY)a7'1-292 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL M
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:JR PLANS SUBMITTED: YES 0 NO❑
FUTURES 7 FLOOR—' BSM 1 2 3 4 5 6 7 6 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 ' 4 •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
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KRONEN SINK RC \/
I LAVATORY ( ! • -- Y� T' _
1 ROOF DRAIN
I SHOWER STALL - • NUV U / X018
! SERVICE/MOP SINK _
TOILET I I Lp..i NG DEPARTMENT
URINAL r.. DI-- _
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
1 WATER PIPING �
I OTHER
INSURANCE COVERAGE:
I I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142.. YES,4 NO 0
IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY,�] 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
L: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 compfi a with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Pe tY JooAa5 UCENSE# 0,7 SIGNATURE
MP? JP❑ CORPORATION❑# PARTNERSHIP Q# LLC❑#
COMPANY NAME pc 1 c i„-e} ADDRESS ' C 1"c ke-m)t c L 1
CITY
KJ/7'i.°oi-h STATE rt A ZIP 0J C0 7.7 TEL Ca a37-5 -7
FAX CELL EMAILr , Co rat C K,S/ "A-7—
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