HomeMy WebLinkAboutBLDP-24-197 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
r— CITY✓o`I G� /�,,,2�r7U�'� MA DATE o`� PERMIT#
JOBSITE ADDRESS �,/�
e y /Q./7,2- 4'fp/G OWNER'S NAME T%TO R/i Ref/
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P OWNER ADDRESS 1I TEL77f j2 O%b3FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 J RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT' PLANS SUBMITTED:YES❑ NO
FIXTURES 7 FLOOR- 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 RECEIVED
TOILET
URINAL FEB 2 6 20i4
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES X — —
WATER PIPING 6Uil-UIN,=EP Tr
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO Rr
IF YOU CHECKED YES,PI FASF INDICATE 111E TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY❑ BOND❑
ER INSURA C W R:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
/�and nthatm{y signature on this permit application waives this requirement
"1'"/ ./ CHECK ONE ONLY: OWNER,'AGENT❑
SIGNA RE OF OWNER OR AGENT
I hereby certify that a1 of the details and Information I have submitted or entered regarding lids application are true and to the best of my knowledge
and that all plumbing wait and'installation performed under the permit issued for this application will be in compfm Pet of the
Massachusetts State Plumbing Code7T and Chapter/142 of the General Laws.
PLUMBER'S NAME CI I��"p)e/c l ,€ e' LICENSE#3/079. RE
MP❑ JP" CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME ADDRESS 6 ! /3?/71 y$ ,9 u O �l/
CITY H 1/41//r-h S STATEM ZIP 0�1 / TEL-17 L/ 5c� /45-7
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FAX CELL77y55ig6 67EMAIL(1,1k-1 4CQLiLcce,057; /1IP74"
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