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Home My WebLink AboutBLDP-18-003734 ''s MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK - CITY IG. Tin MA DATE h? a PERMIT#/ p'lS-av a799 ___ ., JOBSITE ADDRESS l6-7w %t-AA Rd timairerkiry OWN ME P 2 ta SO U-�'� S/ , l� r-d t -�1 ©l 0 3 FAX OWNER ADDRESS C Q Y EL TYPE OR OCCUPANCY TYp� COMMERCIAL❑ EDUCATIONAL El RESIDENTIAL yi PRINT -(1'1 DA CLEARLY NEW:1 RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 7 FLOOR--I BSM 1 2 3 4 5 6 7 B 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 - LAVATORY t I . ROOF DRAIN SHOWER STALL 1 SERVICE I MOP SINK I. TOILET 1 I I URINAL . WASHING MACHINE CONNECTION • WATER HEATER ALL TYPES 1 WATER PIPING t _ OTHER - _. -\ . INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YEStifr NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY yr 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 t° 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 compliance with all Perti P/t nent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE* 2 1(09 ii SIGNATURE MP ❑ JP CORPORATION CI# PARTNERSHIP❑.# LLC❑# COMPANY NAME �a ye-1n C. f`u n413 et' ADDRESS )c s s-(,) 29 CITY..J/ COe 4- STATE� d- (o © J 0 ZIP j 4 TEL O - 3283 �' da V O,Ve. e EMAIL Pl u b er.,COM, FAX CELL 4f2/i Hye- 004CIDa ?�WWWCO ..