HomeMy WebLinkAboutbldp-19-006526 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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tilq CITY VAII t''JU` MA DATE 0 N/ 1 S1 19 PERMIT# fr/0d
JOBSITEADDRESS 42 'J2t)'0Q OWNER'S NAME ALFA COI) eoi-y
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
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CLEARLY NEW:❑ RENOVATION:®, REPLACEMENT:❑ PLANS SUBMITTED: YES® NO❑
FIXTURES Z FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 2
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) ( v
KITCHEN SINK �.
LAVATORY 1. 2-
ROOF DRAIN
SHOWER STALL 1. t
SERVICE/MOP SINK 1. _
TOILET 1 2
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 go NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW u \ E
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND ❑. fsiz „eh.
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OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by0hapter142 of the
Massachusetts General Laws,and that my signature on this permit application ' uirement
/,- C ECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT //
I hereby certify that all of the details and information I have submitted or entered rega application are true and accurate to the t of my knowledge
and that all plumbing work and installations performed under the permit issued for this application wNI be in compile with aft P rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME S/_VJoik) 3t?/a LICENSE# At t 6 1 I URE
MP®. JP❑ `' " 5 fireittRPORATION❑# PARTNERSHIP # LLC❑#
COMPANY NAME ADDRESS 3� I C.24 0 'V s.T .L
CITY IA A N L)/k) STATE KA ZIP 0 2-3 4 TEL
FAX CELL ?e! - 420 IS3 EMAIL Da0-"pLvh3i>JCiA*j i t`iNC7e /ik J- CJI�'1
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