HomeMy WebLinkAboutBLDP-16-006064 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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Wta s>ti^� MA DATE Y Sll„ PE,R/MIT#�209—A,' 1(� '
JOB 9tTE ADDRESS y/ fief,/u ps. `` OWNER'S NAME volt*) redSeA/4
OWNER ADDRESS Et( (La 1 • TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL❑
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO❑
FIXTURES 1 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/OIL/SAND 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 I
ROOF DRAIN
SHOWER STALL ,
SERVICE/MOP SINK
TOILET 1
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER E4eam_ , I'
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES VNO❑
IF YOU CHECKED YES,PLEASE INDICATE
THE JNPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY INSURANCE POUCY L►3 OTHER TYPE OF INDEMNITY 0 BOND❑
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❑ 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 in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER' NAME LICENSE#%tie3 SIGNATURE
MP PLUMBER'
❑ CORPORATION U rf I rj 3 E PARTNERSHIP(❑# (�/) LLC❑#
COMPANY NAME"1 4 I l 1 A Lw �.y.�a ,a. ADDRESS 3 •�tf� It.1(.
CITYt'"(Fers Y STATE ZIP (914jSI TELcoe'/ 3 Or?,9
FAX CELI .0)?3?O'? EMAIL r
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