HomeMy WebLinkAboutBLDP-23-11639 6------0)74
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MASS CHUSETT UNI FORM APPLICATION FOR A ERMIT 0 PERFORM PLUMBING WORK
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CITY 111 7 l MA DATE 6 7 PERMI# ..z3 -//6
' f C al V0s NAME - V • (9)
JOBSITE ADDRESS
POWNER ADDRESS .r TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[ —
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7 FLOOR-+ BSM 1 2 3 4 5 6 7 6' 9 10 11 12 j 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 17 '
DRINKING FOUNTAIN
FOOD DISPOSER r K E C E I 11
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) -
KITCHEN SINK NUa 2)
ROOF DRAIN
(3 1/ ►T
SHOWER STALL 21
r,,- - $,:__
SERVICE!MOP SINK •TOILET
URINAL
j WASHING MACHINE CONNECTION "---' .
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE: l ��
I have a current liability insurance policy or its stantial equivalent which meets the requirements of MGL Ch.142. YES 8<10 ❑
IF YOU CHECKED YES, PLEASE INDICATE T TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ OTHER TYPE OF INDEMNITY 0 BOND ❑
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 [I]
SIGNATURE OF OWNER OR AGENT
',.1 I hereby certify that all of the details and information I have submitted or entered regarding this application are true a accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complia ith all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S E LICENSE# ,
� ��� SIGNATURE
MP JP CORD RA ION . # PARTNER ❑.# LLC ■#
COMPANY NAM h0 �.,. I [19(--) . hi
/ ADDRESS i iu i
CITY ,V4 `� I'�'
1 STATE il ZIP (�� 7 -7-7 TEL.':K.f . .iO
FAX CELL E ' ` c-,`j