HomeMy WebLinkAboutBLDP-23-8494 #1124 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
. MA DATE PERMIT# QLOP-Z3 SL9q��
MAY QI�B°*fAD t4 RE S L }� �/.
_..,_, c�/�'th �F� OWNER'S NAME c. : - S
R LDING 0 W,, DNT BRE S TEL
FAX
TYPE-0R -4CCtiPANCY. E COMMERCIAL
PRINT EDUCATIONAL ❑ RESIDENTIAL❑
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:L
PLANS SUBMITTED: YES❑ NO 97
FIXTURES 7. FLOOR-* BSM 1 2 3 4
BATHTUB 5 6 7 8 ' 9 10 11 12 13 14
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
SERVICE/MOP SINK
TOILET
URINAL
j WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER y. i 6'
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES M NO
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BEL ❑OW
LIABILITY INSURANCE POLICY [1 OTHER TYPE OF INDEMNITY ❑ BOND
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not the insurance coverage required b Chapter 14
= Massachusetts General Laws, and that my signature on this permit application waives this requirement. y p 2 of the
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT ❑
LLI I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accy..te to
and that all plumbing work and installations performed under the permit issued for this application will be in co .'
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. . --eft provision of the
the best of my knowledge
= ce'�;
PLUMBER'S NAME 1411R41-> 14
LICENSE# SIGNATURE
MP JP❑ CORPORATION❑#
COMPANY NAME wm' ,•'-on PARTNERSHIP❑.# LLC❑#
ADDRESS 4 N G'n, In �wc.A
CITY��,� ••,- ' �I c,
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