HomeMy WebLinkAboutBLDP-15-000024 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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3, t= 10 CITY. YAP m o E��!( MA DATE 7/10/5y PERMIT# Pic Og
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JOBSITEADDRESS Gd /e1TA ,4fiE OWNER'S NAME Sa¢I, r F
POWNER ADDRESS y1 /1 TEL tS'I-Yffc-0.1$x, FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL
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CLEARLY NEW:0 RENOVATION:0 REPLACEMENTS PLANS SUBMITTED: YES❑ NO❑ ,
FIXTURES 1. FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOILISAND SYSTEM
DEDICATED GREASE SYSTEM ,
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
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FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR) ;......J1
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KITCHEN SINK
LAVATORY 1
ROOF DRAIN
SHOWER STALL K ' ( /b 1
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SERVICE I MOP SINK
TOILET —
URINAL
WASHING,MACHINE CONNECTION
WAT RHEAIECALETYIPE3 E D
WATER Wiltfp b�-�,�
OTHER �.. r `7_(/
11114
BUILDING D W TMENT
°Y•--- ,Fell)________ INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YEN' NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY* OTHER TYPE OF INDEMNITY 0 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 Law ;and th y signature on this permit application waives this requirement.
. ti CHECK ONE ONLY: OWNER AGENT 0
SIGNAT RE9 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 t. •e best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be In compliance wi all '-rtinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER'S NAME 1Y113 j:; L O&tcE_d LICENSE# /JQe 7 SIGNATURE
MP JP❑ CORPORATION pJ#at{ ?Z C PARTNERSHIP❑# LLC❑#
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COMPANY NAME/CC-74)WYA71131R 114417'6 ADDRESS .9.3 Lincoln A&E,
CITY PA1'7tit l/e- STATE{114 ZIP Ca-76 4L TELj -04-CCS-q
FAXS4'4ggl'SS.S"C1 CELL EMAIIFa3i )ff iribmC attest t'cr
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