HomeMy WebLinkAboutBLDP-23-11808 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
c:_ °�;Y CITY )6(wv C�)h . 1 I- MA DATE OC I • �CJr a PERMIT# RZ.,QI'-23-- ilk6 S'
JOBSITE ADDRESS I3iuc/1 1 I 1 fe OWNERS NAME T }I l j pce t YkerQv
pOWNER ADDRESS TEL 7V 1 360 40c01 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIA'
PRINT
CLEARLY NEW:0 RENOVATTOK REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR--' BSM 1 2 3 4 5 5 7 8 9 10 11 12 13 14
BATHTUB _ - - _ _
CROSS CONNECTION DEVICE _ _
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASfOILfSAND SYSTEM - - ,
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
-DEDICATED WATER RECYCLE SYSTEM
DISHWASHER X _ _ - 1
DRINKING FOUNTAIN I
FOOD DISPOSER
FLOOR f AREA DRAIN
-INTERCEPTOR(INTERIOR)
KITCHEN SINK X - -
LAVATORY
ROOF DRAIN
SHOWER STALL - - - -
SERVICE/MOP SINK I
TOILET
URINAL
WASHING MACHINE CONNECTION i
WATER HEATER ALL TYPES ` - -
WATER PIPING
OTHER - .
INSURANCE COVERAGE:
I liability insurance pol': substantial equivalent alent v,hi h meets the rarn•irr, tints MCI rh 1,12 YES 0 !!O n
have a current tia�:...}:..s;..:u;,c..--'icy or its J,Aal�.4t,.R4,eris:.,ra1...,\N.tIW,Ifi..,:+.,the,WiVN w,l...,w of MCI_,s,�. , YES u ..: `j
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY Q BOND 0
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 0 AGEN I U
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 a o the of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in comp It rti ' ion of the
Massachusetts State Plumbing Code and Chapter 142Loffthe General Laws.
PLUMBER'S NAME P'((CIIVI Sau�'€4t� LICENSE# 34-l7'f SIGNATURE
MP❑ JPX] CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME scar ( 13v;,)l (1 e 7 ADDRESS 13q f h kook ((,
CITY .0 ifi nc'Kicolf- STATE MA ZIP 0),631 TEL 7 7 f 1 670.AT
FAX CELL 774 q-0 7 EMAIL R,..50)(555 ymoii( e-oir