BLDP-19-002065 V
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MASSACHUSETTS/UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY Yth�7 !7U//L� MA DATE II�J��/� UI `ODo2C '1
�/ / C ` PERMIT#
JOBSITE ADDRESS a ,*W!/u#1t/ >i OWNER'S NAME /7/6/6/(./ •c401h,
POWNER ADDRESS tl Ya, TEL • FAX
TYPE OR OCCUPANCY TYPE COM ERCIAL 0 EDUCATIONAL 0 RESIDENTIALA
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:0 PLANS SUBMITTED: YES 0 NOEI
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14
BATHTUB _
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM f
DEDICATED GREASE SYSTEM `
DEDICATED GRAY WATER SYSTEM i •
DEDICATED WATER RECYCLE SYSTEM / _
DISHWASHER
DRINKING FOUNTAIN I
FOOD DISPOSER
FLOOR!AREA DRAIN J _
INTERCEPTOR INTERIOR
KITCHEN SINK I � ( i
I LAVATORY , •"
ROOF DRAIN '
SHOWER STALL I ),) 211 r
SERVICE I MOP SINK i
! TOILET I BUIL('i A —1 f
URINAL '' _L I's"" _ s • ,-1(Q
WASHING MACHINE CONNECTION i
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES.1Z NO ❑
IF YOU CHECKED YES, PLEASE INDICATE TH TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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
iMassachusetts General Laws,and that my signaturet.
on this permit ap?lication waives this requiremen
i CHECK ONE ONLY: OWNER 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT
14.1 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 compliant wi II Pertinent provision of the
Massachusetts State Plumbing Code and Cha,ter 142 of the General Laws. LS
PLUMBER'S NAME
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LICENSE#QO U SIGNATURE
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MP�] JP 0//jj���� ,,/� /CORP�O/RATTIION 0# PARTNERSHIP 0# LLC d#3< /
COMPANY NAME �/1 076C4 `(A /t 6 ADDRESSSS`8/&!/ 1.V''f/ �d•�lY �}�
CITY �l�L/G ` STATE/14P ZIP 02(.4-25. TEL�JO4 Ofl?55
FAX CELL EMAIL
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