HomeMy WebLinkAboutBLDP-24-146 main bld /4r9-inJ bU(I-4)(dG
MASSACHUSETTS UNIFORM APPLICATION FOR AFPERMIT TO PERFORM t°LUMBING WORK
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MA DATE PE MIT# Q(,17 P-2,4 "/t-rG
JOBSITE ADDRESS `,I b OWNERS NAME --"r
POWNER ADDRESS TEL FAX_
TYPE OR OCCUPANCY TYPE COMMERCIAL ID EDUCATIONAL El RESIDENTIAL I
PRINT
CLEARLY NEW:0 RENOVATION:Ls REPLACEMENT:n/ PLANS SUBMITTED:YES LW NO 0
FIXTURES 7 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 I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY 2
ROOF DRAIN
SHOWER STALL - - —8J1t=3•W �,-.,h TMF —
SERVICE/MOP SINK --, --
TOILET -,
URINAL '
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER -1 2/4NS"f-- J Yt"VVLI %
INSURANCE COVERAGE: �..-
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Q NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POLICY 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 0 AGENT 0
Z 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,ccurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in comptian ith all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'SNAM�E//J r>'p,r,�d�-( Pcu1O LICENSE# G5�/J(q SIGNATURE
MP JP L� L{y�h „r `'1 ICOORRPORATwION_J❑# PARTNERSHIP 0# LLC 0#
COMPANY NAME
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CITY / 1 V14OVT�� STATE/V ZIP ( TEL-5
FAX CELL EMAI im 1
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