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HomeMy WebLinkAboutBldp-20-004783 cA P PcA c WL5?) MASSACH SETTS UNIFORM APPLICATION FOR A PERMIT T PERFORM PLUMBING WORK g Urn �j y�,� C/ CITY V lam' I / / MA DATE ✓ g© PERMIT# /✓XO/'OZO`� l 70 JOBSITE ADDRE S '7a oQ`/ 'bLjd og IV OWNER'S NAME POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ E UCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SU MITTED: YES❑ 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/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATERSYSTEIvI DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET 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 lEfs. NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY A 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 ❑ 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 complia ith all Perti rovision f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 67 ) PLUMBER'S NAME C c r t • ecl e l l LICENSE# �"ay(� SI ATURE MPM JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME C G r 1 1=_ R ecl Z it r S o n ADDRESS 77 zS M a r, 5 re e CITY O5te r V i II e STATE IliA ZIP U Co 5 5 TEL 5o-- H - Lo 3(o5 FAX CELL EMAIL