HomeMy WebLinkAboutBLDP-19-005137 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY Yar m o v4L - Vies+ MA DATE 3 /S /19 PERMIT# „fin
JOBSITE ADDRESS al Ca r V c r R ti OWNER'S NAME S4,ey e IAA i re
POWNER ADDRESS S CA -e— TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL Xs
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CLEARLY NEW:0 RENOVATION:7 REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO 0
FIXTURES Z FLOOR-4 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/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 3. I.
ROOF DRAIN
SHOWER STALL I
SERVICE/MOP SINK
TOILET I ,
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
UABILITY INSURANCE POLICY 73 OTHER TYPE OF INDEMNITY ❑ 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.
CHECK ONE ONLY: OWNER 0 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 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 ir�,cQmpr n with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /��//1
PLUMBER'S NAME LICENSE#/02 r)IGN LIRE
MPX JP 0 CORPORATION❑# PARTNERSHIP+ ❑# ` LLC 0#
COMPANY NAME 1'\V O1 O r'v^1 i ti Y, � 2 lam 14 ADDRESS T ✓+^'3°e-1 J1 V�
CITY w Q-S t" 60 ` c O v STATE MA ZIP 0 IS A�D 3 1 TEL S "# -1—'
FAX CELL S a'"► EMAIL l v l K 1�F L ® NISI i '�J ._... $
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