HomeMy WebLinkAboutBLDP-23-11926 i14P,, Pd '76. 66
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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i(11C7,A' MA DATE )M-1 Li?) PERMIT#/jLDP-Z3 //94•
JOBSITE ADDRESS Ct CtUV X OWNER'S NAME R c- i- C o(Cc"it
OWNER ADDRESS - — TEL — FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL❑ RESIDENTIAL Er
PRINT
CLEARLY NEW: RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO❑
FIXTURES 1 FLOOR-r 95M 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOIUSAND 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 R C C E t V f
URINAL
WASHING MACHINE CONNECTION D 2C 0 7 2023
WATER HEATER ALL TYPES
WATER PIPING BUILD NC D_nARTMrN' j
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. YESiO' NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY td OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:lam 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❑ AGENT 0
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 Inc an no a Pe nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME Pulph(� r jrQ p�r, LICENSE# 9 33`"} SIGNATU E
MP NI JP 0 CORPORATION #S990C. PARTNERSHIP❑# LLC❑#
COMPANY NAMES &Mt-`(M `, 4 0 c 1 T ' ADDRESS I VS- allo_ S1^.
CITY 1�nni��o(�r J STATE(VW ZIP 03% TEL .`02-39�-?> -(to
FAX RCi 'FN_tom' 1 CELL — EMAIL 0 F I Cc(a 3Telorriodn,r e
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