HomeMy WebLinkAboutbldp-19-004963 I--1. ' 7 Th/. 1%� `e j j
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
k .j L_a CITY/TOWN d A1 \/&S v,4 6 L MA DATE a, 8" / PERMIT#t/-1'�0 y
JOBSITE ADDRESS 5 -b k‘VA-W OCk) OWNER'S NAME �c. \SIll f(e -
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL NI
PRINT
CLEARLY NEW:( RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB I
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM ,
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER 1
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN [1,
INTERCEPTOR(INTERIOR)
KITCHEN SINK , i
LAVATORY �j
ROOF DRAIN / (/
SHOWER STALL I I
SERVICE/MOP SINK
TOILET 1
URINAL
WASHING MACHINE CONNECTION 1 I ' II
WATER HEATER ALL TYPES ' i07 41yoi2
WATER PIPING
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OTHER
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO.41
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY ❑ 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.
CA/` - CHECK ONE ONLY: OWNER cV AGENT ❑
SIGNATURE OF OWNE OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this applicatio e an t the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be m ian i I rtine t provision of the
Massachusetts State Plumbing Code nd Ch ter 142 of the General Laws.
PLUMBER'S NAME .�'P Z(Cn LICENSE# 1 2 ./� SIGNA RE
MP(: JP 0 CORPORATION 0# PARTNERSHIP 0# f LLC❑#
COMPANY NAME \ ��� �'�' 0 0,1k'J i Qs ADDRESS 90 /1J9A1 RIP
CITY I ) 4- -k4Y liii CIA STATE I"l a- ZIP Q 6) / TEL
FAX CELL > / �'`Jd�)S'2Z EMAIL 'b1k.) __r 0 0.__e1A4L AS4 . Nei
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