HomeMy WebLinkAboutBLDP-23-8532 /0 O. ®a
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY \ &rm 0 V fi1 MA DATE • PERMIT# �'D I 23— gL 3 Z
JOBSITE ADDRESS 3 3 l T b o r Et/` OWNER'S NAME 3 1-e...0 el lei
OWNER ADDRESS 3 3 kr b U ( TELL ill )0 g$d$ FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:' PLANS SUBMITTED: YES 0 NO 0
FIXTURES 1 FLOOR-4 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/011JSAND SYSTEM _
DEDICATED GREASE SYSTEM _ _
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR 1 AREA DRAIN
INTERCEPTOR(INTERIOR) R P t.► i V t.F.- 0
KITCHEN SINK
LAVATORY
ROOF DRAIN 2 3 2023
SHOWER STALL
SERVICE/MOP SINK BUILDING DEPARTMENT
TOILET By
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES I \
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,' NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY INSURANCE POLICY 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 0 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 • «. pliance with all Peru nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAMERO-}C-c CA‹.. )2vvk1S'j LICENSE#3 aq-7 % A/Ltr7ti JSIGNATURE
MP 0 JP, ] CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAMED V\A �(\U(Y11J th C6iDDRESS Li a O
CITY CO+t� STATE // ZiP 02 6 3 5 TEL I g) �/� 779 „
FAX CELL1e' (g 110b EMAIL Grn.a; a 1 S �✓l