HomeMy WebLinkAboutBLDP-19-004091 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY �''1 MA DATE / /� /5' PERMIT#/I A :-0SIC•l
JOBSITE ADDRESS 7) AE'/v/ti / lC` OWNER'S NAME �/09 0' e'ev
OWNER ADDRESS TEL. �� �� 7�yc FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL
PRINT /
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:f�, PLANS SUBMITTED: YES 0 NO❑
FIXTURES 1 FLOOR—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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/AREA DRAIN , G ° .A
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY IA N 1 1 'Q 1
ROOF DRAIN L.
SHOWER STALL
SERVICE/MOP SINK --
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
t have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ErNO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY QV-
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
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 and rate the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application wdl be in.• .^_ provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S UCENSE# SIGNATURE
MP JP❑ CORPORATION[ # PARTNERSHIP❑# LLC❑#
COMPANY NAME //f v ,/*// - ADDRESS /t2 4 y y
CITY 8/Z.eZ S/ e,_ STATE /1/12/4- ZIP D Z Gp .3 ( TEL �� � 7,1 j�2
J �
FAX CELL EMAIL i fLr 7YJ 7 i'Z�fr1 . &0
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