HomeMy WebLinkAboutBLDP-23-10697 MASSACHUSETTS UNIFORM APPLICATION FOR A CITYPERMIT TO PERFORM PLUMBING WORK
t;ikit-vr�GtA.43� MA DATE tV 7/ 1._3 PEAT /3-L3-/0!a 97—
JOBSITE ADDRESS OWNERS NAME 4 61-I 19. ll G 2
P OWNER ADDRESS 3\\O gc q 4-ew'4-70-0`I] TEL FAX_
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0--
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑— PLANS SUBMITTED:YES 0 NO❑
FIXTURES 7 FLOOR-r 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/OIUSAND 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
TOILETC E V E
URINAL -
WASHING MACHINE CONNECTION '���� �� n� '
WATER HEATER ALL TYPES J ���� 2023
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 POUCYr0 - OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I a re'tFiatthe lice see does not have the insurance coverage required by Chapter 142 of the
j Massachusetts General Law that my signatur _this permit application waives this requirement.
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CHECK ONE ONLY: OWNER❑ AGENT E
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application am true and accurate to the best ofr knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in comp) all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. --.
PLUMBER'S NAME LICENSE#clog---7 . �—SIGNATURE
MP❑ JP 0 l� CORPORATION 0# PARTNERSHIP❑.# LLC 0#
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COMPANY NAME oyCrt,✓bQ P 4- ADDRESS ? bled-)(.. S.
CITY r)e-nel,`J I �JSTA�TE v3 ZIP 0 2-17 3 C. TEL 617e io i 5) q/
FAX CELL 5r0"4---�, EMAIL . epnr.,__0Cal (VI - t . CaN-�
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