HomeMy WebLinkAboutBLDP-20-002351 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
k" CITY/TOWN c S• y,47aicr MA DATE /0/21 liqPERMIT#,D1.Qp- e-ma;l15/
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JOBSITE ADDRESS � 6` l tit r �� OWNER'S NAME �E� W
OWNER ADDRESS - TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL E'
PRINT
CLEARLY NEW: 0 RENOVATION: ❑ REPLACEMENT: EY PLANS SUBMITTED: YES❑ NO[�
FIXTURES Z FLOOR-' BSM 1 2 3 4 5 6 7 8 9 10 11 . 12 13 1
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK - f
_LAVATORY E ._,
ROOF DRAIN _
SHOWER STALL4 ltI '
SERVICE/MOP SINK
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TOILET rk,'i=-
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URINAL _
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER gi/tr
INSURANCE COVERAGE: —/
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES pd' NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY IPl 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 a I Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME 13ri A.J -,4 r- el LICENSE# /117 7 SIGNATURE
MP Rr JP 0 CORPORATION W# PARTNERSHIP❑# LLC❑#
COMPANY NAME CAA. C,041 Plan)6, 17 d'A f1b.1j Z'L ADDRESS ,P D, do X L/2.1
CITY Sa r>I &Ake S STATE Mi., ZIP p Z 6 b TEL s P-35'8- i22 P
FAX CELL EMAIL Ca jac&lislJi1iai bA r c1 @ yt loop . �
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