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HomeMy WebLinkAboutBLDP-24-531 MASSACHUSETTS UNIFORM APPLICATION FOR A P RMI TO PERFORM PLUMBING WORK >1 LOp-Z`I- CITY J MA ATE (� PERMIT#4 5 - I1' A r�JOBSITE ADDRESS S OWNER'S NAME POWNER ADDRESS VII It rff-- TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL❑ RESIDENTIAL.❑ PRINT CLEARLY NEW❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO 0 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 F �,' V:-E FOOD DISPOSER _-A_ — FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK ' U NG Po�MENT LAVATORY • 3UIED ____. ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET '—.---" URINAL WASHING MACHINE CONNECTION - WATER HEATER ALL TYPES / WATER PIPING - pTMy Lai%) Si a).‹.., INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Oil°D IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY [0. OTHER TYPE OF INDEMNITY 0 BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 1 Massachusetts General Laws,and that my signature on this permit application waives this requirement. Z SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0 L`.l 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 I co pliance with all peyfinent provision of the Massachusetts State Plump f;ode and Chapter 14 f the General Laws. ��.1/".1// PLUMBER'S ME ob/ �`/Sf LICENSE# I`f'-1 SIGNATURE MP JP❑ / CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME Ay°� S V✓ ""S ADDRESS`/ D/a` CITY D L/LAIS STATE -eta, ZIP Ud�3 TEL FAX CELL/ 3'�-3 i/7/ EMAIL G✓G i -� t C .SOY\