HomeMy WebLinkAboutBLDP-20-001177 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
E €j_ CITY/TOWN /A-4Ntittik, MA DATE IT t PERMIT#/LDn/O /17 7
• JOBSITE ADDRESS O a ..ttok.kor 4$4g- Ems- OWNER'S NAME Ee 54 w) P k o r Cam,
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL(:J
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO❑
• FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 I 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
DRINKING FOUNTAIN _ f
FOOD DISPOSER a R C E I V E 1-
FLOOR/AREA DRAIN w
INTERCEPTOR(INTERIOR) +.I lu I
KITCHEN SINKAl
LAVATORY t � I
ROOF DRAIN { ; �C1N
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 are that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachus-.mot:nd at mAignatur?thi permit application waives this requirement.
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�� CHECK ONE ONLY: OWNER ❑ AGENT
• NTURE R AGENT Z
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 #i t provision of the '
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME `C1-4. e "J 0.',1.w'-t_ LICENSE#JA12/6 SIGNATURE
MP 0 JPyi CORPORATION 0# PARTNERSHIP❑# LLC 0#
COMPANY NAME Sf t v c n E uc ),'n y4 44-G Y /i ADDRESS L Ct e'yc-A-1
CITY ?G r- e 14,.E.1+ STATE AAA ZIP 02`7< TEL g 776 /07/o 2..
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