HomeMy WebLinkAboutBLDP-17-002634 pik ) .
' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY l fLwtCvjl1 MA DATE /0/AC /` PERMIT#naP/7-0al4/
JOBSITE ADDRESS 1/7 w/i-gi/3,L Dc'fl 121? OWNER'S NAME 5r si6-42 hi
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P OWNER ADDRESS 7 C, 5a-ern 5T TiVAefln rTK TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL ,
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
FIXTURES 1. FLOOR-. . ESM 1 2 3 4 5 6 7 _ 6 _ 9 10 11 12 13 14
BATHTUB I
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM i-->
DEDICATED GREASE SYSTEM T
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEMit/
DISHWASHER / y
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) _
KITCHEN SINK / 1�
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET /
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES /
WATER PIPING _
OTHER •
INSURANCE COVERAGE:
I haveacurrent liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[gi NO 0
1 WtrCAECKE gS, LEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
m
`y f LIQ U tIS)RANGE POUCY 0 OTHER TYPE OF INDEMNITY 0 BOND 0
I!! ER'SJNSU^.N E WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
hl.achu'SBtts in i:, aI Laws,and that my signature on this permit application waives this requirement.
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CHECK ONE ONLY: OWNER 0 AGENT 0
(SIG ATURE OF OWNER OR AGENT
IrXefebgtertify-that A of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
Landlga1,i31I plumbinn ork and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
Massachusetts . - Plumbing Code and Chapter 142 of the General Laws. -7
PLUMBER'S NAME LICENSE# 1100. SIGNATURE
MP Eg. JP 0 CORPORATION MI PARTNERSHIP❑# LLC❑# i
COMPANY NAME CP Cu4-w14 PLt.wrfswt4 +H,aWHI ADDRESS p,o, 1So,c '; 11
CITY 1,40T11 4KAT+f A`9 STATE 14-14 ZIP 0 A CS-O TEL )2Y- 3 S3- £fol es--
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