HomeMy WebLinkAboutBLDP-24-135 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
-' CITY /9"-ofiOdrifr MA DATE a/A/ PERMIT#3LOP 2`7- i 36
JOBSITEESS O17 ,C//// Vwd Q • OWNER'S NAME�/0/-1A1- y1
/XO
OWNER ADDRESS / E TEL 7, / -4 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL❑ RESIDENTIAL RAX
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO❑
FIXTURES 2 FLOOR-4 BM 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 I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING/
OTHER ✓
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES LINO 0
IF YOU CHECKED YES,PLEASE INDICATE TH TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIURY INSURANCE POUCY OTHER TYPE OF INDEMNITY❑ 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 E 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 a to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co iSn h i rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. —�
PLUMBER'SR' NAME ,e.Yrw3 r''1 -NAl jk' LICENSE# f 61 jt SIGNATURE
MP,L�/ JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME 't/e #4/J5/Al ADDRESS /6 f /U �k .
O '
CITY 7:714/D0/7F STATE/04 ZIP ( TEL (IDS-SP-WO
FAX V30'6755— CELL EMAIL C193 1 pa CON