HomeMy WebLinkAboutBLDP-19-002979 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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11— • CITY/TOWN VAAPOIttinentr MA DATE l i/13//P' •24 taut .PERMIT#624/2W-CO
JOBSITEADDRESS / 00 N(AI'AcrWaoJ Pt 0 )7 y/I OWNER'S NAME PAtd P7crr0N�` �
OWNER ADDRESS TEL FAX r
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCA IONAL 0 RESIDENTIAL lEFA6 o 'bn
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES 0 NO I"
FIXTURES 7 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 I AREA DRAIN
INTERCEPTOR(INTERIOR) •
KITCHEN SINK I
LAVATORY
ROOF SHOWER STALL RECEIVED
SERVICE I MOP SINK
TOILET FIfV 12 20Th
URINAL
WASHING MACHINE CONNECTION a, a DING o1 pnRTMFNr
WATER HEATER ALL TYPES e -------
WATER PIPING
OTHER
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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 IV OTHER TYPE OF INDEMNITY ❑ BOND ❑
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
aaand
dd 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 comp all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME I3rri1.,/ H f hhAr LICENSE# f/577 SIGNATURE
MP Ltd JP 0 CORPORATION 2# PARTNERSHIP 0# LLC 0#
COMPANY NAME L4-Pc 4 cdt/n*S' nrl + N6J7VI7 Z'-ADDRESS P o, KSaX 9 z.1
CITY 5D6,74 Dc ,/1 STATE/lla ZIP b Z 66 U TEL 531' — ,3Sa' — 2-2Zj
FAX CELL EMAIL
770 -zA �nid- '21