HomeMy WebLinkAboutBLDP-20-000656 - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
4 CITY y4r2MO(17 / PERMIT#/ 22 I �/�n MA /DRAT ���` ./sue+/'f" ` � �''�"�
JOB SITE ADDRESS /— L(�'!"�r`7 Z I L� OWNER'S NAME f4a c7`t'
OWNER ADDRESS 5�9440- TES66219 36 ' FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[ '
PRINT
CLEARLY NEW: ❑ RENOVATION:X REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO I
FIXTURES Z FLOOR— BSIv1 1 2 3 4 5 6 7 6 9 10 11 12 13 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
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
i LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE!MOP SINK
TOILET
URINAL R E E V t D
. WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING A 1G 0 2011
OTHER •
B ILDIts G E ART 1ENT
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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"( NO 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Ki
OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
11 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 acc ate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in corn • ce I Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER'S NAME T / LICENSE#3 606E5 SIGNATURE
MP❑ JP *0 CORPORATION❑# PARTNERSHIP(`(#mom1Csw /�LLLC❑#
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CITY ,042.s7'/✓S-Me ATE / Tf4 ZIP 0To-Pi-esp�[1 —8 TEL✓` -4 7 0 c 67
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