HomeMy WebLinkAboutBLDP-17-000510 ,_. MASSACHUSETTS UNIFORM.APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
�1 CITY Sgt t. xrnilMulti MA DATE !'aS-110 PEEJRMIT#n4DP"/7 6/kt: a
' JOBSITE ADDRESS_ 01,01'R n OWNERS NAME l 1J �/.I CTn r
P. OWNER ADDRESS E tHCtrtPorct- vQ,. thdovictet Stet '
ugto9 l�
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 ED TbONAL 0 RESIDENTIALLY
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO EY
FIXTURES 7, FLOOR-0 BSN 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASJOIOSAND SYSTEM _
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK _,__•_,
LAVATORY
ROOF DRAIN _
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING recrtarS toLfilbin), l
OTHER
INSURANCE COVERAGE
I have a current Iiabiliw insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES'NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING TIE APPROPRIATE BOX BELOW
LMBIU1Y INSURANCE POLICY 13 OTHER TYPE OFINDENINITY ❑ BOND 0
OWNER'S INSURANCE WAIVER:I am aware Matte licensee does not have the Insurance coverage required by Chapter142 of the
Massachusetts General Laws,and that my signature on this permit apphcationyaiveg this requirement
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the doss and information I have submdted 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 prima tared for this application will be in stance wrothalPertinent proutslw�pfthe
Massachusetts State Plumbing Cade and Chapter 142 of the General laws. p[ 1 /j
PLU,M_B/ER'SNAME Grai Zishop. LICENSE ft IblO1 SIGNATURE
MP IV JP❑ JJ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME Hktc h 1-17l A ADDRESS Sll R.loctfre. 13O
CRY Sondvoirtn STATE M& ZIP 0r1.`KpTEL 3(23-Bas-5CAS
FAX cat EMAIL nn011(.(QhiQh-CPPICIPnCt'/�C•CoYV)
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