HomeMy WebLinkAboutBLDP-16-007644 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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JOBSITE ADDRESS I. i I a1I fe _ pCi OWNER'S NAME I Q r �
OWNER ADDRESS L 6 F}jca.P. j TEL A -715 -/7AFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ® - - RESIDENTIAL M1
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:[a PLANS SUBMITTED: YES❑ NOD
FIXTURES Z FLOOR-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB elin Om( lnt am am Om rim Om l
CROSS CONNECTION DEVICE j ,i NM"Miff MR Int
DEDICATED SPECIAL WASTE SYSTEM am rim Om immi Ism am
DEDICATED GAS/OIUSAND SYSTEM NM MN Irk MIK MI 1011101 MIN Om OW=UM IM Om
DEDICATED GREASE SYSTEM NM INK'I II II N'Sow OK 11111111,11111101
DEDICATED GRAY WATER SYSTEM lain l WM 1111111.11.1 Ian Mit 1(NM h`NEW Milli OM Om
DEDICATED WATER RECYCLE SYSTEM �11111111r OM Mit ellu Omit*II'NM AM loll lint
DISHWASHER mg ow mit Miff inir int ImirIn m'inst Int tom imor 11111111•111
DRINKING FOUNTAIN 11111111ii NM INM lin OmI am ram omi ugmrim
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FOOD DISPOSER Mg Ms JIM,Ism 111•11111111 MIN!: 1111111.01111 Inn INN
FLOOR/AREA DRAINMill Mai r ME MK MK o iI i� MIN I�
INTERCEPTOR INTERIOR PM OM, ��� r- m!:s i AM Off
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KITCHEN SINK Ifni am`mum min ant gni litmim ins 'N
LAVATORY Inn MI Mr Mt limn gm ont Oullim limit loom;n
ROOF DRAIN V I I I M um Ir Om Om O-1111111111111.1
SHOWER STALL MR OM Ina Int Irk r 111111 m Om Om linur ;
SERVICE/MOP SINK linin 11111111.INK i .M,ice[__Jim somi In Ulm
TOILET MI MM.IMI MI MI 111111:11111111'v Miff NMIi am Ilam
URINAL A Oil___ Om inn Mum Jim P
WASHING MACHINE CONNECTION MIR In.low iim ismrmow m 111111111.111 Mil Aim IaaIOnt
WATER HEATER ALL TYPES 11111111 1011111111111 IMF NINE MINI_Imo:Milli MI"MN MI MINI UMW
WATER PIPING INN rI I ( rte_ am! Iim I� I i � '
OTHER �_ OMM'MN OEM PurlMIK 1111111ff MIN1111.MIK MK 1111111111NM MEI int am am lam ma am oar am Omit
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ow nit pm Om pm am rilui w Mit MIMI JUNI,
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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 ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 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 ❑ AGENT Li
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 in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# il� SIGNAT
MP El JP❑ CORPORATION(✓6# PARTNERSHIP❑#MIN LLC❑#
COMPANY NAME j2tlsTy TidC. 1 ADDRESS I aaa Mid-Toch Ori✓c
CITY W. x9✓m � I STATE N),¢ ZIP 02473 ! TEL 5b —77,f=/3a3
FAX co 77//-93/0 CELL 111111 EMAIL
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