HomeMy WebLinkAboutBLDP-23-11373 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
MA DATE -20"23
JOBSITE ADDRESS PERMIT#/ L ' Z 3` f
W Itch A)O yp l' OWNER'S NAME Z 1 4
r OWNER ADDRESS
TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Lld"
PRINT
CLEARLY NEW:0 RENOVATION:
REPLACEMENT.❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7 FLOOR-+ esM 1
BATHTUB 2 3 4 5 6 7 8 9 10 11 12
CROSS CONNECTION DEVICE 13 14
DEDICATED SPECIAL WASTE SYSTEM -=
DEDICATED GAS/OIUSAND SYSTEM _11.1111111
DEDICATED GREASE SYSTEM -11111111111
DEDICATED GRAY WATER SYSTEM _111111.111
DEDICATED WATER RECYCLE SYSTEM --
DISHWASHER _�
DRINKING FOUNTAIN -�
FOOD DISPOSER --
FLOOR!AREA DRAIN _IIIIIIIIIII
INTERCEPTOR INTERIOR _-
LAVATORY =-
LAVA 111111111111
ROOF DRAIN11.111111111
SHOWER STALL _
TOILET SERVICE
/MOP SINK
ILIMMIIIIIIMIIIIIIIII
111111111111111111
WASHING MACHINE CONNECTION �1_
WATER HEATER ALL TYPES ��=pi����
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OTHER �� �
��I have a current IlabIII insurance policy or its substantial riam11111.1111111111
leq va ent which meets the requirements of MGL Ch.
IF YOU CHECKED YES, PLEASE INDICATE TH TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 142. YES rt. NO 0
LIABILITY INSURANCE POUCY OTHER TYPE OF INDEMNITY 0 BOND 0
•1 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not ave the insurance coverage by required Chapter 142 of the
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 0► : OWNER 0 AGENT
I I hereby certify that all of the details and information I have submitted or entered regarding this application areArab
and that all plumbing work and installations performed under the permit issued for this application will be in • •m
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. a flu.... "
to the best of my knowledge
P :��all Pertinent provision of the
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PLUMBER'S NAME1?r�S l�` �,C)
LICENSE# R26 Iq
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MP JP❑ • SIGNATURE
CORPORATION❑# 2-087 PARTNERSHIP❑.# LLC #
COMPANY NAME C+3 Ll,,,,,� r �„ ❑
CITY f�?�l-�L� � ' ' 1 �}?1f`� �ly� ADDRESS 0 �rD) �S�
FAx STATE�' �= ZIP G261 �{ TEL °� �77-G I Z
CELL I <
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