HomeMy WebLinkAboutBLDP-24-145 cottage #10 60%7/4 /0 r', V /
MASSACH SETTS UNIFORM APPLICATION FOR A PPERMIT TO PERFORM PLUMBING WORK !
• ar I MA DATE 2. 1 Z I
j CITY y �M�U�� PE MIT#�LDD 2 I- !`tl'_
— JOBSITE ADDRESS
'--- --/O/12— D/2-- OWNER'S NAME —"r
POWNER ADDRESS TEL FAX_
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL I
PRINT �,
CLEARLY NEW:0 RENOVATION: REPLACEMENT:' PLANS SUBMITTED: YES LAY N�O 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
FOOD DISPOSER C.
FLOOR/AREA DRAIN -
INTERCEPTOR(INTERIOR) FCo 1/..yo
9 -KITCHEN SINK E
'
LAVATORY
, .I,r-AFt 1 aiF NT
ROOF DRAIN
SHOWER STALL —.a
SERVICE/MOP SINK •
-
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER -7 mS"V , � i P
r 1 /
INSURANCE COVERAGE:
I have a current liabilityjnsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO ❑ 1
IF YOU CHECKED YES,PLEASE INDICATE THE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ 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.
CHECK ONE ONLY: OWNER❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
L.1 I hereby certify that all of the details and information I have submitted or entered regarding this application are true and °curate to the best of my knowledge
and that all plumbing work and Installations performed under the permit issued for this application will be in complian 'th all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME D(po tArro/Ioj W, LICENSE# G5LI(7,6 SIGNATURE
MPIV. JPEK
�{{�, �/J CORPORATION❑# PARTNERSHIP Q#�7�I t {/LLC❑#
COMPANY.NAME I r`�r✓4�'"IT f 4'`7 ADDRESS�c^,W 7 IV/V 7
CITY `/,4gV4Q'V �7' STATE it4i) ZIP I TEL
FAX CELL EMAI
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