HomeMy WebLinkAboutBLDP-23-10688 (2) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
,. .t-~Ir ` A �r✓1'lL )'1 MA DATE 06( '�/202
PERMIT# LOP-______23 ___
JUN ()� T ADDR S 5 ' A ee too„� l R OWNER'S NAME ✓ o
OWNER ADORE.S 30 1 V a vi{o k o a�;( (6-5-2
B i_,,,`4G „L rARTMENT
.. : ==••"..,_ & PE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0
FIXTURES 1 FLOOR—+ BSM 1 2 3 4 5 6 7 8' 9 10 I 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE J ____,
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 ,----1
INTERCEPTOR(INTERIOR) _
KITCHEN SINK
LAVATORY
-
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
j URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER De in 0 J 0 X
INSURANCE COVERAGE:
Ti
{ I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES, . NO 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY OTHER TYPE OF INDEMNITY ❑ BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
i Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT ❑
Z. SIGNATURE OF OWNER OR AGENT
kA.I 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. f
PLUMBER'S NAME LICENSE# '3 5e3 2 _C SIGNATURE
MP❑ JP Ok CORPORATION❑# PARTNERSHIP❑-# LLC❑#
COMPANY NAME W1 e&S'e it- JO IA G Cl ADDRESS .2 4 0 fk0 vi do P p ) 5
CITY We IM 0 ufk STATE 1t/t/-- ZIP O Z (3 0 TEL C3 S/_ ° _T`( 7
FAX CELL EMAIL to wi�' (\yt 8 0) I,vl a e(. 6
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