HomeMy WebLinkAboutBldp--19-001477 4 MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM PLUMBING WORK
-,= 5 CITY C/� tMOA MA DATE 1' [—‘$ PERMIT#/*/Y -00
JOBSITE ADDRESS'C) () tall, ,\ 5� OWNER'S NAME Wit ' 10. 61pan '
POWNER ADDRESS a 6( `� SI B). itIR TEL 7 \ attct `{ \ FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL E EDUCATIONAL ❑ RESIDENTIAL pa
PRINT
CLEARLY NEW:❑ RENOVATION:g REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7. 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/OIUSAND SYSTEM _
DEDICATED GREASE SYSTEM _
DEDICATED GRAY WATER SYSTEM _
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER I •
DRINKING FOUNTAIN P "E i V CL Q
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) )f f I 201 i'
KITCHEN SINK I I
LAVATORY - - _
ROOF DRAIN
SHOWER STALL _�-.
SERVICE/MOP SINK
TOILET
URINAL
. WASHING MACHINE CONNECTION
WATER HEA I tK ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES4 NO 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY 1( 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 Law a that my signature on this permit application waives this requirement.
A / CHECK ONE ONLY: OWNER AGENT El
SIGNAT 0 OWNER OR AGENT
Is&I I hereby certify that all of a 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 compliance with rtinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �% e�f��
PLUMBER'S NAME \OI 1,v.. 4 J LICENSE#' a1.t(a . SIGNATURE
MP❑ JP lI CO ORA1TION 0# PARTNERSHIP 0.# LLC 0#)
COMPANY NAME ,,J ,.1tim UM�b,,r` ADDRESS 6 ��► ci B� � �(J
CITY � 1 44611 1r\ STA A- ZIP 61664 TEL rIDS a37• c94
FAX CELL EMAIL ►1 \J Vn C
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