HomeMy WebLinkAboutBLDP-23-11645 MASSACHUSETTS UNIFORM APPLICATION FOR
A PERMI TO PERFORM PLUMBING WORK
I r CITY ) > G ^ r' MA DATE
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PERMIT# I/�/�`L3 iikr-
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JOBSITE ADDRESS I`; / 7 'a . 5e-i OWNER'S NAMED q yi )-10-l i ...
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P OWNER ADDRESS t� /7 TEL 7 57-6 7 1 + FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:Q RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 2 NO❑
FIXTURES 7. FLOOR--+ 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 E (., I
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER ri,--,i. 6 20g21) . ______.DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREADRAIIV LuiLCiNC t1E.vnR nAFNT
INTERCEPTOR(INTERIOR) - �^
KITCHEN SINK
LAVATORY / —
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL -
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Z OTHER TYPE OF INDEMNITY ❑ 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 ❑
SIGNATURE OF OWNER OR AGENT
�I 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 all 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.
PLUMBERS NAME LICENSE# b�. �� I � �
1n� '� SIGNATURE
MP❑ JP p P CORPORATION❑# p t" PARTNERSHIP❑.# / LLC El#
COMPANY AME 1j ()) r i e ADDRESS f-'l-qi l a 1 L - -�
CITY ) q A A 3 STATE L+ ZIP e - 4 0 / TEL )-7 t/ ifi Yi -Z.--
FAX
CELL EMAIL -- .'�ij,a/` 01 c(J ('I e,e, Ci it.4 1 L ` (O``-