HomeMy WebLinkAboutBLDP-24-141 cottage #6 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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,� CITY MA DATE PE 4W 21 i H
JOBSITE ADDRESS S�Shn. e , OWNER'S NAME -"'r-
POWNER ADDRESS TEL FAX_
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL Lam'
PRINT
CLEARLY NEW:❑ RENOVATION:V REPLACEMENT: PLANS SUBMITTED:YES EXO 0
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
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. .
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER _
DRINKING FOUNTAIN
FOOD DISPOSER E . E EMiii
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK I F i . 1. l
LAVATORY • II
ROOF DRAIN - G O;.
SHOWER STALL -
SERVICE/MOP SINK —
TOILET
URINALI II
. WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING OTHER j.rrN 7-472, L yO
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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 Ile 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
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Massachusetts General Laws,and that my signature on this permit application waives this requiremen
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
L1J 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 compllan 'th all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NA,,,MMM���E///,, DIPoNtlitrOPOU(_p.A LICENSE# /'yq6 SIGNATURE
M NAME f r`��Jr T14 ADDRESS 4/�[CORPORATIONL. #0 PARTNERSHIP
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CITY V 41 f"`I OVT t+ STATE M 4 ZIP f TEL
FAX CELL EMAI 1
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