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HomeMy WebLinkAboutBLDP-16-003436 _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 1 • 4...cr-e \ alajth MA. DA r= 1 1 i al( PERMIT# g40 /46-Ca 3q/� JOBSITE ADDRESSYftSOQc�- ;Q� OWNER'S NAME�U11l rn �1'61 e.(.1 POWNER ADDRESS c1/4.--"-`5CI-- 2.._, ,- ---- TEL;�(} -1 ( (\ AX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW ❑ RENOVATION: ❑ REPLACEMENT 0) PLANS SUBMITTED YES❑ NOt FIXTURES Z FLOOR— BSM 1 2 3 4 5 6 7 i3 9 10 11 12 13 t4 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 I AREA DRAIN ~ • I INTERCEPTOR(INTERIOR)_ KITCHEN SINK LAVATORY ROOF DRAIN - - SHOWER STALL SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES I " 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 El NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT ❑ I hereby certify that all of the details and information I have submitted or entered regarding this application are:true 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©ropli n with all Pe nent pr vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBERS� NAME T&o' 1j l a- LICENSE# ,N q SIGNATURE MP L'u PP❑ n CORPORATION Errt 3(4140 PARTNERSHIP # COMPANY NAME - Ylh ri 3 O ttm.. ADDRESS k eu I S s ' 261 CITY _ 0 STATE. 1 ZIP 0).4'l TEL 14m & l 5 FAX 4O g31. 1015 CELL Li 0 45 48210 EMAIL n , ' .(0171 - \ L \ , , I . . 1 , . , . ,. , ! , • , , , , 1 _ , , , I 1 . , ; , 1 1 , , , I . 1 , , , 1 1 , , , 1 1 i i 1 1 2 .._ ...,- . „..: - z it ..- . _ _ ... _ I 11011. Ca _----------------------1 Ili LL- . i - i I . 1 _ I . i . , . _ I _ I 1 i I 1 . ,I I . , . . . 1 I . I I _ . . 1 I . . 1 . , I ! i i 1 1 , I ! . • . I 1 i , 1 . I ; i i 1 , , . , . \ . , . . 1