HomeMy WebLinkAboutBldp-19-005623 . [PO c" r Q/Pi.
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
lark — CITY Aj a"-r+u--7r11 ` ? PERMIT# /'
/( 1 —�-.0 J6..23
MA DATE r 7
JOBSITE ADDRESS /60 U /h OWNER'S NAME (/'ih/ m
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL ll:'
PRINT
CLEARLY NEW:( RENOVATION: re- REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO❑
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 w _
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM x'"
DEDICATED GRAY WATER SYSTEM ` A
DEDICATED WATER RECYCLE SYSTEM C
1 R Zd
DISHWASHER / •
DRINKING FOUNTAIN ?. P
FOOD DISPOSER I
FLOOR/AREA DRAIN z imp
INTERCEPTOR(INTERIOR)
_ KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL •
SERVICE!MOP SINK
TOILET F _
URINAL
WASHING MACHINE CONNECTION /
WATER HEATER 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. YES"NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY V/ 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
° 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 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 liance Pe r'e provision f the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME V c c1' /10-W LICENSE# ?p f SIGNATURE
MP ❑ JP[V CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME / -- ��-C 4jL- ,�4' � ADDRESS /o/ 6 Qv—e-4-1
CITY STATES ZIP 0 6 c/ S� TEL C-0 0--02 c//7
FAX CELL EMAIL Oct c,t oI 17 dL 04 6 tJ &G/'t a
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