HomeMy WebLinkAboutBldp-19-003693 ip/T POOR
OKA/
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY_ v 7 yc4lof4acJl1 MA DATE /Zi/3/-P° f PERMIT#%:K/,/2-/P--00.YO ✓
JOBSITE ADDRESS 29fb v f/h' / 44.0274 OWNER'S NAME t10,5 1 '6oG o
OWNER ADDRESS 2T V#''-C Jr Lam/ TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL[le--
PRINT
CLEARLY NEW: RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO[
FIXTURES 1 FLOOR-4 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
LAVATORY f
ROOF DRAIN
SHOWER STALL ['
SERVICE/MOP SINK
TOILET I II i.
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING I I.
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY INSURANCE POUCY 0 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 Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
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 ac to to est f my knowledge
and that all plumbing work and installations performed under the permit Issued for this application will be in ce ail ne vi ' f
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBS ' AME LICENSE# /0 377 SIGNATURE
MP JP 0 CORPORATION 0
# PARTNERSHIP # LLC #
A COMPANY NAME f s � ADDRESS 3 m gh/" '6907,17
CITY W s r y4.--41 I O vT 7" STATE * ZIP 124 7.1 TEL
FAX CELL EMAIL jotAdiQ,e49 rJ/AtAl 9/4/1, GO'si
1\f\