HomeMy WebLinkAboutBLDP-22-007086 i/0.0b
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
��' ' �YrY//ic�Cl MA DATE V PERMIT# LZ- �OBE„
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// 1014, 44-ro Pie OWNERS NAME ' r�- "j
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PAY 3 i c R ,ID"ESS -LA n-,,r, /< TEL FAX
B CE''.®Br 1At TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
CLEARLY NEW: ■ RENOVATION:[REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7 FLOOR— BSM 1 2 3 4 5 6 7 9 10 11 12 13
BATHTUB - 14
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM / , _ . ______
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM1 \ . ______.
DEDICATED GRAY WATER SYSTEM (
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK 7\\ ._,-- . _ ,
_
LAVATORYall< . .0
ROOF DRAIN
SHOWER STALL X ;t f
•
I SERVICE/MOP SINK
TOILET j,C _ _
URINAL
j WASHING MACHINE CONNECTION -
i WATER HEATER ALL TYPES - _
WATER PIPING
OTHER
I
i -
INSURANCE COVERAGE:
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 POLICY ❑ OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
1 Massachusetts General Laws,and that my signature on this permit application waives this requirement.
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SIGNATURE OF OWNER OR AGENT
CHECK ONE ONLY: OWNER ❑ AGENT ❑
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 knoedgf
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.
PLUMBERS NAME
LICENSE# 37 G,y.� SIGNATURE
MP❑ JP El. --
_ CORPORATION 0# PARTNERSHIP Ott LLC #
COMPANY NAME r� � -1--01 ❑
ADDRESS �es- nticiwtv, Sio2::)R
CITY o k kfl alto% -t•- STATE I" ZIP_c_ (`ate
FAX Y TEL g��� b
CELL EMAIL