Loading...
HomeMy WebLinkAboutBLDP-23-11388 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK i CITY \) / \t,\Du ..3 PERMIT# S D Z3- t I '3 99 '� MA DATE (G , JOBSITE ADDRESS 7 '12"•i--A .ti'/ ,,:;..,iT L,.t\i'\L -- OWNER'S NAME Q iv.i w-. ' . & POWNER ADDRESS r'`P1 TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL E EDUCATIONAL ❑ RESIDENTIAL©'"/ PRINT '- CLEARLY NEW:®' RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 7 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 0 BATHTUB 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 ROOF DRAIN �', SHOWER STALL i SERVICE/MOP SINK --....mr.r..rlr"11 TOILET 1 nNi URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES i ! WATER PIPING OTHER [utD Gut ILN I IIIw ' .i INSURANCE COVERAGE: "If I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES a NO 0 IF YOU CHECKED YES, PLEASE INDICAT E TH/5TYPE 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. . CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT LI I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the bess 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 prevision of the, Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# c 1. . ,_..4../-44:?.' ( 7 7 r J SIGNATURE' F in MP❑ JP a.. CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME r, C.g / f I f ADDRESS -�y Ca L-- -4-1< t I c.; CITY ��If -- V 1I �� STATE !t II, ZIP ,. ` TEL -A.. .t- :7 . -{ FAX CELL EMAIL