HomeMy WebLinkAboutBLDP-19-000301 ✓Pa✓61.74 ro L5-tr'�t
t • ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY t 0Otti MA .TE i.r • PERMIT#6WP-Melee/
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JOBSRE ADDRESS i. /. M �' OWNER'S NAME
OWNER ADDRESS TEL TEL �\JJFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL'
PRINT
CLEARLY NEW:0 RENOVATIONS REPLACEMENT:D. PLANS SUBMITTED: YES ❑ NO'.
FIXTURES 7 FLOOR—. ESDI 1 1 3 4 5 6 7 6 9 10 11 .12 13 14
BATHTUB
CROSS CONNECTION DEVICE •
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/DIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
IN tXCEPTOR(IN I tHIDR)
_ KITCHEN SINK
LAVATORY
ROOF DRAIN
I SHOWER STALL 1 /
SERVICE/MOP SINK
I TOILET
URINAL
• i WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
I WATER PIPING /
OTHER
INSURANCE COVERAGE: _
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MC L • s \o 2D
IF YOU CHECKED YES,PLEASE INDICATE THETYPE of COVERAGE BY CHECKING THE APPROPRIATE BOX BaO.N JU 6 202
UABILITY INSURANCE POUCY\IA OTHERTYPEOF INDEIANITY 0 BOND 0 3A •
BUILDING DEPARTMENT .
• OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage reqs fired by_Chapter 142 te
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
1-34 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 cam ance with • Pero/'t provision piths
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / ,
PLUMBER'S NAME LICENSE#367/ . SIGNATURE
MP ❑ • JPA CORP RATION❑# PARTN HIP❑.# LLC❑#
COMPANY NAME O\ ev / (J iv, ,atea , ADDRESS la /2i< /31 p /
CITY (itbofj�' ierrie)C/n STATETV ZIP C9d 67) TELYO8-774. dJ'&
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