HomeMy WebLinkAboutBLDP-23-11397 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY t4Jt_54 !'airmaatt MA DATE lO/ �/ ? PEl(tdlil-A
JOBSITE ADDRESS 16 spry,e r' Cie < OWNER'S NAME 116(Y`F S6r tyL g n c
P OWNER ADDRESS I Cy1,a, t UYh Le-kn4,4h N.ATEL
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TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Ert,
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:N PLANS SUBMITTED: YES❑ NO
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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/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 l F p ®-- --�
SHOWER STALL r
SERVICE I MOP SINK
TOILET �
URINAL 1. ,
. WASHING MACHINE CONNECTION BUILDING DL AR rOEar
WATER HEATER ALL TYPES _
fWATER PIPING
OTHER 1 -
,S 5 rP7tC /2/ rWA)
INSURANCE COVERAGE:
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{ I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES tJ NO ❑
IF YOU CHECKED YES,PLEASE INDICATE E TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POLICY ] OTHER TYPE OF INDEMNITY BOND El
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 ❑ 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 an 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.
PLUMBER'S NAME/kdfh ile a LICENSE#1(06 ! SIGNATURE
MP❑ JP 17!1 CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME Aft4 COPfri414 p I ADDRESS J ceilFe S�
CITY S T l ' aV�j�ji STATE ZIP a-716 ��-
7� TEL U pp
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FAX CELL EMAILL 61.Z ZWW51414- L,c)