HomeMy WebLinkAboutBldp-19-006006 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY MA DATE 7 ^ 3—If PERMIT#� i��' �(' 6
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JOBSITE ADDRESS' ,R S aA-d e OWNER'S NAME 3(-s5 I��c rityr,fJa
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OWNER ADDRESS c . '• ec'—ArEL FAX LL
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL H-
PRINT
CLEARLY NEW: RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO❑
FIXTURES 3. FLOOR-+ BSIv1 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 A -1? 11111MMINALII•
DRINKING FOUNTAIN
111
FOOD DISPOSER tics _ _E
FLOOR/AREA DRAIN -__-
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INTERCEPTOR(INTERIOR) III 1—
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KITCHEN SINK
LAVATORY / /
ROOF DRAIN
SHOWER STALL /
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SERVICE I MOP SINK
TOILET / !
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 P. NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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 compliance with all Pertinent rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME 3 c-c LICENSE#1325 . SIGNATURE
MP JP❑ rt , CORPORATION #3A y PARTNERSHIP LLC j ,�
COMPAN E C l 0 IL11/� 1 �Q�`�� �
NAM —1 r`'� ADDRESS
CITY I 2-3 60 7 7 3 I V� STATE��I ZIP � TEL 7
FAX CELLDT ("s5 / EMAIL52 A6f7 L y/ t �,rLe�c VC$ •��
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