HomeMy WebLinkAboutBLDP-24-393 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
"= CITY/TOWN c !/+4'1 Ol,M MA DATE y//6/Z t I PERMIT#Bc O P 1`t- 113
JOBSITE ADDRESS 29 CAP1/4CRCP1 L Sr- OWNER'S NAME -1-41i /' 4 Z
OWNER ADDRESS TEL)OIr-717-/Q1p FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL - EDUCATIONAL❑' RESIDENTIAL❑
PRINT -
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENTS' PLANS SUBMITTED:YES❑ NOACI
FIXTURES 1 FLOOR—. 8SM 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 L D
ROOF DRAIN R F C !V
SHOWER STALL
SERVICE/MOP SINK APR 16 20211
TOILET
URINAL BL ILDING DLI-AKI MENT
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, ' NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY❑ 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❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this applicati re a accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will in comp) wit ertinenLhtovisior oof Me
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME ,A/L-1 nO SS[: LICENSE# J,S"adJ. SIGNATURE
MP1,4 JP❑ CORPORATION 0# PARTNERSHIP❑# _ f LLC❑#
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COMPANY NAME Se C/ipc '1/SSiG ADDRESS P-)• D J
ox. 1359
CITY (- bG/unll S STATE/ ZIP ea 66 0 TEL
FAX CELL.S O8 fair' i 7C EMAIL RZ0.1B(R bAn)R( 6 I hi L • nM