HomeMy WebLinkAboutBLDP-24-193 'M,A/SSACHUSETTS UNIFORM APPLICATION FOR A�PERMIT
/TO PERFORM PLUMBING WORK
VIl CITY iJav naa—!h MA DATE A/O�ih/n�`C PERMIT#kOP 2.1-1— 113
JOBSITE ADDRESS 582, /?.Odk a8 OWNER'S NAME Jahn KesQv!S
OWNER ADDRESS 5ga ROu1-e A TEL TILL 306•A78¢FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NOA
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 6 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 R[FEB
C C F=I V r
FOOD DISPOSER
FLOOR/AREA DRAIN n'INTERCEPTOR(INTERIOR) 2 202 I
KITCHEN SINK
LAVATORY '.
ROOF DRAIN -'„"'�•+� �NT
SHOWER STALL
SERVICE/MOP SINK 1
TOILET
URINAL
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 E, NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 1"' 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 and that my signature on this permit application waives this requirement.
�� / CHECK ONE ONLY: OWNER AGENT 0
SIG OFOrdRORAGENT
I hereby certify that all of the details 555nd 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. //�(i�,w`1`
PLUMBERS NAME 4/f/cMde/ f/Dad/ey LICENSE# //4t// IGNATUR
MP j, JP 0 II / CORPORATION/ 51#.1V7Ci PARTNERSHIP/ 0# L LLC❑#
COMPANY NAMEUOM Y,// d/y /umb/c y ADDRESS X!/:y7A Ur/J/�/7 JT • �p p pG
CITY Al/JGf I,Il if / STATE MC) ZIP a... 7J0 /_TEL �/"s7/O'OQ/0
FAX CELL�I".3 '//off r EMAIL rn Ana kyt9/I LY1(//eyer1d 5Onc•(6,71