HomeMy WebLinkAboutBLDP-17-003456 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �y-
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�/ J�vr. MA DATE I j 4I ll PERMIT# 44017-ou 2yc&
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JOBSITE ADDRESS I L11 VJGb txceS r+ru-` OWNER'S NAME tD 17-C
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
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CLEARLY NEW:0 RENOVATION:p REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
FIXTURES 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
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DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM l
DISHWASHER /\
DRINKING FOUNTAIN /A
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FOOD DISPOSER -
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) ^y
KITCHEN SINK
LAVATORY I \
ROOF DRAIN \\ `
SHOWER STALL 1
SERVICE I MOP SINK
TOILET I •
URINAL
. WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING I
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESP NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POUCY ia 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
1 Massachusetts General Laws,and that my signature on this permit application waives this requirement.
`l CHECK ONE ONLY: OWNER 0 AGENT 0
Z SIGNATURE OF OWNER OR AGENT
L11 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 all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER'S NAME Z"\ tokkot LICENSE#30 evi . SIGNATURE
MP❑ JP,l CORPORATION❑# PARTNERSHIP❑# LLC 0#
COMPANY NAME \c p I...t1/44t.4.,1 ADDRESS 0.0`Dp (Sr
CITY �QYV'L65,�J-V1 STATE F'`e ZIP 0lid 35 TEL 77t'C-242^ZLbg
FAX CELL EMAIL
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#111$213d $ :333
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