HomeMy WebLinkAboutBLDP-24-143 cottage #8 C T (OT i -
MASSACHUSETTS UNIFORM APPLICATION FOR 1A-PERMfII TO PERFORM P UMBING WORK
1_r ;z CITY y4ZM6U1" J MA DATE 2 f 1 z 12L 1 PE MIT# -DP-2`I- i'13
JOBSITE ADDRESS yr2.E
Die_ OWNER'S NAME �T
POWNER ADDRESS ''r TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL❑ RESIDENTIALLY
PRINT
CLEARLY NEW:0 RENOVATION:ri REPLACEMENT:' PLANS SUBMITTED:YES LVVNO 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/OILISAND SYSTEM
DEDICATED GREASE SYSTEM —
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER 7 - -
DRINKING FOUNTAIN
FOOD DISPOSER —
FLOOR/AREA DRAIN - R EC- rv—`—
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY • — FEB 2 -
ROOF DRAIN
- t 3
SHOWER STALL uiLLrrvu JI_PARIMCN}
SERVICE I MOP SINK • EL---_---
TOILET
URINAL -
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES :
WATER PIPING
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OTHER 1 VJ NS-ri5A e—'V 4yl1
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY INSURANCE POUCY 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
1 Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE ONLY: OWNER 0 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,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.
PLUMBER'S NA,�MM/E D tAf A" Ot'oL1571,
s LICENSE# L/cSIGNATURE
MP JP LI ` CORPORATION 0# PARTNERSHIP
❑.# LLC 0#
COMPANY NAME I ✓6- ---r (4'Pi ADDRESS Z5 4J77 iV / A O
CITY / 4g0"tO/ 4 STATE M ZIP ( TEL-5-
FAX CELL EMAI
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