HomeMy WebLinkAboutbldp-19-006543 /nAP : PRAeEG :
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
_ C [ i4 ! V I Q_cc!' Jl .I MA DATE PERMIT#,--d/Ctir-ad r
JOBSITE ADDRESS 11 r, 2Ci 1 OWN 'S NAME 2(,s s C/ 4(tickQ - `I i
OWNER ADDRESS TEL ;(:) - ,0:) FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL'
PRINT
CLEARLY NEW:® RENOVATION:ID REPLACEMENT:Er PLANS SUBMITTED: YES® NO1
FIXTURES 1 FLOOR--► BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB -IN MIMI'EM R liltCROSS CONNECTION DEVIC --s
DEDICATED SPECIAL WASTE SYSTEM DEDICATED GREASESAND SYSTEM • U n i, • RINI
DEDICATED GREASE SYSTEM III Mil
DEDICATED GRAY WATER SYSTEM .:
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) awl
KITCHEN SINK
LAVATORY 11
ROOF DRAIN
SHOWER STALL
TORE/MOP SINK ILET a.MO' 1111111 mar'nommirm
iniummirlostwureiriur
URINAL 111111111111111111111111111111 111111111 Mil 11111111111111 Nor Ali Mai
WASHING MACHINE CONNECTION ' ' L M M'M';MN M M M'M MIN M'
WATER HEATER ALL TYPES RANIER RR1111111111Rigarn
WATER PIPING
OTHER _ --- - _-- -- _
Rognmann
ammilimmitannuinnsioI
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ct.1R. ffSIq E D
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 9
LIABILITY INSURANCE POLICY 1 OTHER TYPE OF INDEMNITY BOND ® PAY 17 2Q19
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by i gFi7 E /' Pi"
Massachusetts General Laws,and that my signature on this permit application waives this requirement L, _
CHECK ONE ONLY: OWNER ® AGENT El
• 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 and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in cane+'nce with all ro ' ion of the
Massachusetts State Plumbing Code and Chapterap� 142 of the General Laws.
PLUMBER'S NAME I<P,,t1 t` ..�t�_613(-,CJ e_._ !LICENSE# I (7a0 1 SIGNATURE
MP JP® CORPORATION #oRFaC, 1PARTNERSHIP®# LLC[ #
COMPANY NAME L ;g j CB,,de. P4 .. ADDRESS
CITY W. fv,0•.,4A STATE ( 4_ ZIP da67 3 TEL - (5OS)��i` 455e
FAX boo 7rcu-'af CELL(501)3t4.37 EMAIL 4601 (-plumb cofrflAS4 ;� e.-i 1
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