HomeMy WebLinkAboutBldp-19-005934 ''w MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
v L . CITY V i Dl MA DATE y��efi�' PERMIT# i�19 QO Y
,,,_ , JOBSITE ADDRESS (.5 Siena k OWNERS NAME Ze/1,1 t 7 '/,"a/3
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL.
PRINT
CLEARLY NEW:❑ RENOVATION:, REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ 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 I _ •
_
DRINKING FOUNTAIN
FOOD DISPOSER 1:7 r ,:: `
FLOOR(AREA DRAIN
INTERCEPTOR(INTERIOR) _ _
KITCHEN SINKli qa.4.ti _,
LAVATORY _ 1 - _
ROOF DRAIN r
SHOWER STALL / .
SERVICE(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.. 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
l.\ 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 provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. >Y .
PLUMBER'S NAME ..0'414. Ira//l.owsri LICENSE# 3.3ICI q. SIGNATURE
MP ❑ JP [ CORPORATION❑# PARTNERSHIP D# LLC❑#
COMPANY NAME (t plvmaA..., * Hi/dC ADDRESS P1 &'x /311.1-
CITY W Gsf- GH4/1 akj STATE Al- ZIP Q 046 f TEL
FAX CELL 77 ti_did--cv5g EMAIL St.—p ivi►,b,by eyedtvels‘eiri
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