HomeMy WebLinkAboutBLDP-19-003347 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
�• :51 CITY/TOWN Win %gap?0u r/MA DATE
I 11/30 /1 CY PERMIT# /J,n/�V 55
JOBSITE ADDRESS q '7 fib/0 C.e/.•✓/• 71 rcI Lu OWNER'S NAME / ti l/ FL/b a.-c.c
P OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL Lr
PRINT
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CLEARLY NEW:0 RENOVATION: El REPLACEMENT: 0 PLANS SUBMITTED: YES 0 NO Kv
FIXTURES 1 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13
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 LAVATORY SINK R EGEa�
4 _
ROOF
N r 4753
SHOWER STALL "un' R0 'Mt
SERVICE/MOP SINK
TOILET - I
�
y_
URINAL - JO-
WASHING MACHINE CONNECTION
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 Ly' NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY EHEOTHER TYPE OF INDEMNITY ❑ BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
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
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 andininstallations performedpten1 funder thepermit issuedsfor this application will be In compliance ith all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. t�)j
PLUMBER'S NAME Se-/ i44 r LICENSE# //g 77 SIGNATURE
MP Ey JP 0 CORPORATION p•l PARTNERSHIP 0# LLC 0#
COMPANY NAME C.igen• Ac 1-N i n/C • ADDRESS F D t igbo< 9 2-5
CITY 5• De/Vit/ STATE /174 ZIP D 26 6o TEL 53?-31,-2-Z e
FAX CELL • EMAIL
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