HomeMy WebLinkAboutBldp-20-000011 /1?11P : PRAeEC :
1:j, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
j CITY Yli 2 rn �D� H I MA DATE PERMIT#/ 2A O'CAW
LP41-1j
JOBSITE ADDRESS 3 S. ' (Wr r nJ Vr,..^ Dr D . j OWNER'S NAME I Ir':<? Po;
P OWNER ADDRESS TEL1(-7►7) I FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL J RESIDENTIAL Er
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES® NO❑
FIXTURES 1 FLOOR- BSM 1 2 3 4 5 1 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS101USAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
5 , Y
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR 1 AREA DRAIN . II
INTERCEPTOR(INTERIOR)
11111
KITCHEN SINK ,
LAVATORY
ROOF DRAIN I
SHOWER STALL
SERVICE 1 MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION ,-_ _ 115111,111111R11111111___ J
WATER HEATER ALL TYPES timing
WATER PIPING 11:'' —, MIN Mai
-
OTHERg.
' Mimi
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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 2/NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY E 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 0
• 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 comPLIPritys with all ' ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Kw t1 r -..I�l�_c1.8ei j A 1 LICENSE# kdp SIGNATURE
MPDA JP CORPORATION[i#aft~, 'PARTNERSHIP®# _ - 1LLC®# `
COMPANY NAME IEY._i1,A_MC f je_Pt+ji,._, 61_,.__I ADDRESS -I' JV2 d Adi RECEIVE ;
CITY W. Vic,r-r ,`1.A STATE (YEA I ZIP 02.6,-7 3 1 TEL (5 O ; -7-7 , 455
FAX `6of 7'i o-tiA CEl L(.5_O1)3LA-3? EMAIL 1L!Yt ��Q jv.m. �_- i� f o�^� +s �,o iiN 2 8 2019
BUILDING DEPARTMENT
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