HomeMy WebLinkAboutBLDP-19-002484 Att., MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
• — CITY/TOWN yAet/n ° yrOtd7 MA DATE /0/2-(///P• - • PERMIT#t/DP-�00'24
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1 OO 1PA>J, e r tuced JrdUv it II IV OWNER'S NAME I/Jt/1 re-rouoN
JOBSITE ADDRESS
p OWNER ADDRESS TEL �,FAX
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TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL 5O,W
PRINT —/
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:E" PLANS SUBMITTED: YES 0 NO
FIXTURES 7 FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 1
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM•
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM 0
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER \ -
DRINKING FOUNTAIN C�e -
FOODDISPOSER Curl-\\\S� 9.
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) L P�
KITCHENSINK ee
LAVATORY � '��
ROOF DRAIN • \/j
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
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 E /NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Gd" 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE ONLY: OWNER 0 AGENT ❑
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
eaand
d accurate to the best of my knowledg
and that all plumbing work and Installations performed under the permit Issued for this application will be in comer all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,`,,,(j/•{
PLUMBER'S NAME 13rt Aw1/ I bLir LICENSE# ti q 77 SIGNATURE
MP I Ie JP❑ CORPORATION Ij-# PARTNERSHIP❑# LLC❑#
COMPANY NAME CA-PcCod //PA6+nl 1 Nc,t4 jZcADDRESS /.o, 6OIX 9v1
CITY SO4/74 DA'vis STATE/II/dk ZIP O Z 6 G O TEL 3b? - J% ZZZJ
FAX CELL EMAIL
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