HomeMy WebLinkAboutBldp-20-003161 PAP : PigA e eL :
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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JOBSITE ADDRESS AO P . ( , Dr, . OWNER'S NAME,,,, r:r i s o r- 1
P OWNER ADDRESS TEL Q78 .gild 074O f FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL D RESIDENTIAL D
PRINT
CLEARLY NEW:D RENOVATION:D REPLACEMENT:D PLANS SUBMITTED: YES D NOD
FIXTURES Z FLOOR-) BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROCE
DEDICATED SPECIAL WASTES CONNECTION SYSTEM MIERNERRIMIRRIIIIRRIMIN
DEDICATED DEDICATED GREASE S ST ES NMYSTEM MB MI NM MI rgwing
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DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM ingiliiiiiminin
DISHWASHER
DRINKING FOUNTAIN issmonammuninn
FOOD DISPOSER
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FLOOR/AREA DRAIN IIRIIMIRMIIIIIIIII5111•111111
INTERCEPTOR INTERIOR
KITCHEN SINK LAVATORYMIR. RIBRIIIII �
ROOF DRAIN :Ina
SHOWER STALL
TOILET
SERVICE/MOP SINK 111111111=111111.11 .:--
URINAL tit I
WASHING MACHINE CONNECTION si 11-15
WATER HEA i Hi ALL TYPES
WATER PIPING gii nurumwsno inermitimennow norm P'norm,
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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 12/NO D
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY INSURANCE POLJCY ffil OTHER TYPE OF INDEMNITY D BOND D
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 D AGENT D
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 c:Wince with all ro on of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME <'W:1' .il) C.Bri.C)P I LICENSE# I lbu1O_J SIGNATURE
MP RI JP D CORPORATION Nj#02%IC, PARTNERSHIP D# .1 LLC®#
COMPANY NAME I ELMc&.,J eficti. .._ ..I ADDRESS 11�{[�t1r�5P}
CITY W. Vic..r ry.io.a4A 1 STATE (Y)A I ZIP Da 6-7 3 I TEL 6 0 i 17 .., ,, "' 7`
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FAX IA
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