HomeMy WebLinkAboutBldp-19-005754 MASSACHUSETTS` UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY SOU kL YarA1Od / /i/4/67
� MA DATE PERMIT# _ ,
)a ` .1"I I/� L/i1pec my OWNERS NAME A4r4 V� %A/
JOBSITE ADDRESS�n ) // ,,�QI�� C Y
OWNER ADDRESS 200 Mlle Ara41,5k I(IY idui,Afi4 TELfOF- 7-/f q FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL ❑ RESIDENTIAL 11.
PRINT
CLEARLY NEW:❑ RENOVATION:[ REPLACEMENT:❑ PLANS SUBMI I I ED: YES❑ NO L
FIXTURES T 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 GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) +
KITCHEN SINK ? ;' _fi is _
LAVATORY t
ROOF DRAIN 70,
` SHOWER STALL I �'_
SERVICE/MOP SINK — L--
TOILET
a -
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES f
WATER PIPING
OTHER _
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES kr NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 17_1 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
Massach etts Gen ral ws, at my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER VAGENT
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 co Ilan all P 'nent rovi ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME 5-co-I Rei e LICENSE lat iC3Ty M SIGNATURE
MP JP ❑ l CORPORATION❑# PARTNERSHIP❑.# LLC['#F2'2 U'Y26
COMPANY NAME .5Ic I1UW►01h ADDRESS kg)? )0V
CITY aria& 1 f' STATE) A ZIP d.24 TEL AC" V 7
FAX CELL d aj EMAIL 5, LU/41)f446LC4G IL_(04'?
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