HomeMy WebLinkAboutBLDP-19-002684 --a
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
Iaie CITY d 4 f+w✓1'4 MA DATE L D/1 // R" PERMIT#/P2421?-67644t7/P2421?-67644t7/
JOBSITE ADDRESS_ a 1 (p y di '45 OWNER'S NAME ic/�+/) •
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT.V PLANS SUBMITTED: YES 0 NO❑
FACTURES 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 ••
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY •
ROOF DRAIN
SHOWER STALL •
•
SERVICE/MOP SINK
TOILET
URINAL
• i WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES ✓�
WATER PIPING.
OTHER
.
INSURANCE COVERAGE:
I I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ' NO 0 .
IF YOU CHECKED YES,PLEASE INDICATE THETYPE OVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILRY INSURANCE POUCY �OTHERTYPE 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 ap?lication waives this requirement
•
• CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
Li I hereby certify that all of the details and information I have submitted or entered regarding this application are nd accurate to the be of my Imowledge
and that all plumbing work and Installations performed under the permit issued for this application will be In•• ce with all P rovis n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �.."-•%
PLUMBER'S NAME D l h.-A LICENSE# a-3 so,c- SIGNATURE
MP❑ JPQQ 1
n CORPORATION❑# PARTNERSHIP Q# LLC❑#
COMPANY E 4 nt ADDRESS
CITY rttn c( STATE7.64± ZIP D�'-/J[)/ L/ r/' TEL C-0 8~a-ij .1— 0 W7
FAX CELL EMAIL£4 v/e/FF�r,2 (o ® C/f-41/
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