HomeMy WebLinkAboutBLDP-24-144 cottage #9 )€-C--/-7 \Mc-K-6-1 --0--7-7-fiCT-6 4k 9'
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
1- CITY y►��M6 Ul'I1 MA DATE L 1 / PE MIT# )L_2 h-I`___
�O 4 r, brz
JOBSITE ADDRESS OWNER'S NAME ---"r
POWNER ADDRESS TEL FAX_
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL LW
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:' PLANS SUBMITTED:YES[0 0
FIXTURES 2 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/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM 1 -
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN -
FOOD DISPOSER
FLOOR/AREA DRAIN R E G G_ Q V ._ D `
INTERCEPTOR(INTERIOR) 11L
KITCHEN SINK
LAVATORY ' [ 2B FES 1 r
ROOF DRAIN
SHOWER STALL BUlLDINUDIF Ali Iwrtwi
SERVICE/MOP SINK ' ' uY -__ --- - -
TOILET
URINAL - - -
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES -
WATER PIPING
OTHER Ns� r�I J
I -
_
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POUCY 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
j Massachusetts General Laws,and that my signature on this permit application waives this requirement.
2 CHECK ONE ONLY: OWNER❑ AGENT❑
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 complian 'th all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME ()(p,r tiir f fQt�S �JQri,LICENSE# G� SIGNATURE
MP JP L� L{ �/f CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME I "°r✓{�,t�"'T r 4-p l ^ ADDRESS Z /-&!G d (V/V 7 Igio
CITY `/41g�Qv't STATE!"Y Mil ZIP ! TELS
FAX CELL EMAI
., vrlA