HomeMy WebLinkAboutBLDP-19-005536 -1 J
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MASSACHUSETTS UNIFORM APPLICATIONrL FOR A PERMIT TO PERFOR
M PLUMBING WORA
CITY CiOiS ( 0.,pt-k. L.J+h MA DATE q PERMIT# 'P/9-0O
JOBSITE ADDRESS S 1 c1 Cl J (61 p( yC OWNER'S NAME pI�i J� a '�'r ,-P6ar a,
OWNER ADDRESS S-1' ,,c r
P � �� TEL�7>�'790U,9.(50 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL/ EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES 0 NO
FIXTURES 1 FLOOR-► 8SM 1 2 3 4 S 8 7 8 9 10 11 i2 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
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL ECEIVED
SERVICE/MOP SINK
TOILET
URINAL s ` MAR 2 2319
WASHING MACHINE CONNECTION d u, _ ; PLLii
WATER HEATER ALL TYPES _ I - r�)nsr� anT
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 0
IF 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 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 0
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 trance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME t2 k 11 301 ✓"" ' "
(° L"►�G�' �^,�y r. LICENSE# 33�j SiGNAJ[.l1RE
MPE1 JP❑ CORPORATION # Itv C. PARTNERSHIP❑# LLC❑# •'
COMPANY NAME -S PIu ,ciI,6 + Nee,-, r ADDRESS 1 '� i
CITY kPi'1r►s S P r�' STATE 'Ss" Mai
ZIP Di r�-t 3'1 TEL
FAX <g3 y (6 1-tc-1 CELL EMAIL r) «ef.).3r-o-;poi V ,ii2