HomeMy WebLinkAboutBldp-19-006489-90 1Z., MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM PLUMBING WORK
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v4 CITY_ V a rm 6 u4-\A Pa r-t MA DATE 51 ` 1 Z 0 I q PERMIT#/ P 7
JOBSITE ADDRESS 112. Rke GA OWNER'S NAME LGLtt.t-Ck, L&v<kp,rvHav%
POWNER ADDRESS 6 3S 1{ Ly- 0f a I s k e Dr , N�`1 TEL 4-C 3 O 61x3FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL D RESIDENTIAL g
PRINT
CLEARLY NEW:g RENOVATION:0 REPLACEMENT:0 PLANS SUBMI t I tU: YES[6 NO❑
FIXTURES 1 FLOOR-. = BSM i t 2 i 3 ' 4 5 1 6 7 8 1 9 10 11 ' 12 13 , 14
BATHTUB I 1 1 I I
CROSS COWLCTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM _
DEDICATED GASIOIUSAND SYSTEM
DEDICATED GREASE SYSTEM ? 1
DEDICATED GRAY WATER SYSTEM R i TI
DEDICATED WATER RECYCLE SYSTEM ,l ' , d
I #
DISHWASHER 1 ` i
DRINKING FOUNTAIN '
FOOD DISPOSER
FLOOR/AREA DRAW I
INTERCEPTOR(INTERIOR) + s , l _
KITCHEN SINKy 7
LAVATORY (^ E.
ROOF DRAIN I 1 V 1
SHOWER STALL } 1
SERVICE►MOP SAC . ; I, 4
, MA" t i r
TOILET ! 2uZE r t
URINAL ' I
WASHING MACHINE CONNECTION { F
WATER HEATER ALL TYPES !i - .._.. 3
WATER PIPING i I
OTHER I
INSURANCE COVERAGE:
I have a curert liability insurance policy or its stlbstait ial equivalent which meets the requkements of MGL Ch.142. YES a ND El
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY INSURANCE POLICY Er OTHER TYPE OF INDEMNITY ❑ BOND 0
OWNER'S DURANCE WAIVER I an aware that the fusee does not have the insurance coverage by Chapter 142 oldie
!Aassadiusetts General Laws,and that my signature on this permit application waives this reqiirement.
CHECK ONE ONLY: OWNER 0 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 '.and a•- , : :to the best of my knowledge
and that all plumbing work and installations performed under the permd issued for this aplication will be to•, 1r, .• •, all Pertinent provision of the
Massachusetts State Phanbng Code and Char 142 of the General Laws.. i'. ,
PLUMBER'S NAME n IL f e t t) 4 S UCENSE# 16 4$q f SIGNATURE
MP e1 JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME I)\t4,vvp v1Q So11.t.ho 2 l4
vts o9e ADDRESS A2 Zus-kt 1 Q_Lt4
CITY 1�. Ct.in YI S STATE 14 A- ZIP 0.Z 6 01 TEL
FAX CELL 144-4-22- S 013 EMAIL\t t vrti_ In t1P S 91 e,,t,1 o 0 . Lo wk
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' gJ, ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
vy. ` cny `tarrv\oU.t. Port MA DATE 5 I A5 ` 2.o\Q FAIT# 7-6V6
JOBSITE ADDRESS 1 Z. R t t? 6 A OWNER'S NAME LW.t.ra 1 a vI cti -Wvit Ni
FL 341(3
POWNER ADDRESS(o3$LI .�T�� \s .f Dry Naf�T-.1lt-9 R30-b"3-23FAX
TYPE OR FANCY TYPE CIAL 0 EDUCATIONAL ❑ RESIDENTIAL g
PRINT �/
CLEARLY NEW:0 RENOVATION: REPLACEMENT:0 PLANS SUBMI I i EU: YES t1d NO❑
FIXTURES 1 FLOOR—, BM 1 2 3 1 L 5 6 1 7 d ; 9 10 11 12 13 ' 14
BATHTUB +
CROSS COPRECTION DEVICE I _ _
DEDICATED SPECIAL WASTE SYSTEM _
DEDICATED GASIOIUSAND SYSTEM _
DEDICATED GREASE SYSTEM! i
DEDICATED GRAY WATER SYSTEM i - ,
DEDICATED WATER RECYCLE SYSTEM 1. ,
i -
DISHWASHER I
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN 1 t #
INTERCEPTOR(INTERIOR) 1 - _ -
KITCHEtJ SINKI " ,
LAVATORY }
ROOF DRAIN
SHOWER STALL /
SERVICE J MOP SINK 1 1
TOILET 1 ' F
URINAL 1 i I ,...t. k r:, t:
WASHING MACHINE CONNECTION - ?'_ , 1
WATER HEATER ALL TYPES }
WATER PIPING ` _
OTHER f)41,r A " l A• ( 1 I ,.. . 4
INSURANCE COVERAGE:
I have a current kablity insurance policy or as substantial equralea which meets the requirements of MU Ch.142. YES 6 NO 0
W YOU CHECKED YES.PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER I an aware that the licensee does not have the insurance coverage required by Chapter 142 oldie
Massachusetts General Lays,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that as of the details and information I have submitted or entered regarding this application are true :iY a -•t:.-to the best of my knowledge
and that aft plumbing work and in ns performed under the permt issued for thisapplication v be in-, " Pertinent provision of U+e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /ir '
PLUMBER'S NAME A vN rA r.e w t.tales LICENSE# 16 k g q 7 SIGNATURE
MP Q( JP❑ I0 CORPORATION❑# PARTNERSHIP❑itLLC❑#
COMPANY NAME P I uknAl in �O iu,i;t ak s g,3 '0-cuiesADDRESs ,1 X e u s ii c. Le t,t.2
CITY 4Q a U r�i s STATE µ A ZIP 0.Zfa 0 1 �9 1 TEL
FAX CELL it 4 -12 z - 5 013 EMAIL 1)\Lt.1M 6 — Y1 Lt.t.t e 3 g i @ ) a , Ceotek
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