HomeMy WebLinkAboutBLDP-15-000013 ...4:%N_ MASSACHUSETTS /UNNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
_. e Cr'-', yAIs{(Y1o�/U r 14— MA DATE ft,"'8o'•iV PERMIT# P/77 (�/�
`1 JOBSR /'EADDRESS acEWia'rca. 'Dow r OWNER'SNAMEN
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OWNER ADDRESS /•'i e-D ir-E' UiarER t"a21VE TEL AO 838'33 '13 FAX
O i< TYPE OR OOWPANCY i1'PE: COMMERCIAL 0 EDUCATIONAL 0 RESEEN1 AL 50,1to W I/�`-(� CLPF p R
lie I NEW:0 RB'4OVATION:QJ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO 0
rv'/.z FIXTURES I. FLOOR-. I ?SW pi 2 3 4 5 6 j 7 B 9 10 i 111 I 12 113 14
./ BATHTUB
CROSS CONNECTION DEVICE I I I ' I I
DEDICATED SPECIAL WASTE SYS I I I I I I
DEDICATED GAS101LISAND SYS I I I I 1 I
DEDICATED GREASE SYS I I I I I I 1
DEDICATD GRAY WATER SYS
DEDICATED WATER RECYCLE SYS I I I I I
DRINIQNG FOUNTAIN I I
DISHWASHER I I L I '
FOOD DISPOSER I I I I I
FLOOR/AREA DRAIN I I II I r--
KITCHEN
(INTERIMI I I I
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LAVATORY=-. 1 I I
ROOF DRAIN-
TOILETI
URINALI.
I I I
- *WASHING MACHINE CONNECTION _I
'WATER HEATER ALL. I I
WATER rii - I I I I I
• OTHER Loarr.1 cnnhI. 1 F 1
i JUL Ju .., , i I I I I
• • BUILDING i 1z'•' INSURANCE COVERAGE
`t have.a ea Eh,insurance poky or Its substantial equivalent which,meets the requirements of MGL Ch.142 Yes 12 No El
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LABILITY INSURANCE POLICY ® OTHER TYPE OF INDEMNITY 0 BOND 0
OWNERS INSURANCE WANER I am aware that the licensee does not have the Insurance Coverage required by Chapter 142 of
Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE BOX ONLY: OWNER 0 AGENT ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the datans and Information I have submitted(or entered)regarding this appUcaton are true and acatrate U
best of my Knowledge and that all plumbing work and Installations performed under the permit Issued this application will t
compliance with all Perfinent provision of the Massachusetts State Plumbing Code and 42 a Laws.
PLUMBER NAME crit. 61m A SIGNATURE S_.:0--
LIC it
LICit/5:2,2d NP i( JP❑ CORPORATION ❑I PARTNERSHP ❑I ILC Of
CAIJPANYNAM a - _ .:r I `/ aD & /_ a _
CIN //L;s- STATE/) I ZIPP�4 2 EMAIL. 'C S .: , ', . e•
TEL t c s7 �1 y5(r CHl-2 -�=7470-5(1, FAX
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