HomeMy WebLinkAboutBLDP-23-11700 l MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
e-)"�--- 4 CITY -0/2/ �' - MA DATE Cj I'Z Z�� PERMIT#
JOBSITE ADDRESS J' �' 1 r Y ,, ✓2OWNER'S NAME ?mil
OWNER ADDRESS vLA TELL)IS 'L5Z-
1:1 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTI
PRINT
CLEARLY NEW:--] RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ OE
FIXTURES 7. FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE i
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 , R C E
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPESL ��' 3
WATER PIPING ( ! � 3
OTHER
BUILDING EPAfj ei
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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. Yam❑ NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY-0 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
CC� 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 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 inent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME LICENSE# ' 1 i SIGNATURE
MP❑ JP-❑ CORPORATION[]# PARTNERSHIP❑.# LLC❑#
COMPANY NAME ADDRESS � �c. 6 _
CITY E �t/0�l L IA/16` STATED"k ZIP C7�
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FAX CLL EMAIL SG"61n 11 ) �.1 Li��;