HomeMy WebLinkAboutBLDP-22-005983 il_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
.—
CITYSQI; ' •� ���(rYICX)M I MA DATE f L4 1 1..LU Z PERMIT# �l]1-'l21.00 S
JOBSITE ADDRESS 5ecuCie Y1 y t
lrrG� OWNER'S NAME0. "'
POWNER ADDRESS „
TYPE OR OCCUPANCY TYPE COMMERCIALTELI FAX
PRINT , EDUCATIONAL RESIDENTIAL
CLEARLY NEW: RENOVATION:N..... REPLACEMENT:rx PLANS SUBMITTED: YES I NO.°�
FIXTURES 7
FLOOR-0
BATHTUB BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
E
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM "'
DEDICATED GAS/OIUSAND SYSTEM J
DEDICATED GREASE SYSTEM "� �`�'�`` s-`-= ;` i
k
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM G 1. _ - 1
DISHWASHER
DRINKING FOUNTAIN _
FOOD DISPOSER � �,� .
FLOOR/AREA DRAIN -N. _�-_.- 1, _
p
INTERCEPTOR(INTERIOR) _ _ _._.1
...! f
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK (m
TOILET I
URINAL _ »... _
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING T _._a__.- _.__ - 4 i
• r
IC
OTHER
I have a current liabili insurance policyor its '
_� INSURANCE COVERAGE - -- 1
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
OWNER'S INSURANCE WAIVER:I am awareOTHER TYPE OF INDEMNITY BOND : "
licensee does not have the insurance coverage re
Massachusetts General Laws,and that my signature on this permit application waives this requirement.uired by Chapter 142 of the
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER AGENT U
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and acc in to th.
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. � '-s •f my knowledge
"Pe :' • ovisio he
PLUMBER'S NAME,Richard Olsen U E
LICENSE#.
MP JP # 2166 M10335 !� ATURE
CORPORATION i PARTNERSHIP M;I# 1LLC # -
i
__.__ Heating
— _. -,
COMPANY NAME'Olsen Plumbing& ng ,ADDRESS 1 P.O.Box 2026,357 Hokum Rock Road
CITY]Dennis'_"" .
STATE I. MA ZIP _, _.._.__w__-s:.,
I02638 __.,. ..,
_" — a..�,,,., w _ TEL 508.385 5290 1
FAX 508 385 6963 CELL ;EMAIL _® F _ —'• "'