HomeMy WebLinkAboutBLDP-24-140 cottage #5 2 Z 0677,
MASSACHU ETTS NIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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t CITY MA DATE PE MIT#Q�0P'1""1`l U
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JOBSITE ADDRESS � OWNER'S NAME�..,,W
POWNER ADDRESS TEL �FAX'�_�
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL El RESIDENTIAL L�AX
PRINT
CLEARLY NEW:❑ RENOVATION:V REPLACEMENT: PLANS SUBMITTED: YES Ne NO❑
FIXTURES 1 FLOOR-I 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 J.
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN w--. -� r
INTERCEPTOR(INTERIOR)
KITCHEN SINK I r�
LAVATORY 7 I r rt n 1 (aji
ROOF DRAIN I
SHOWER STALL } ,,,IrawG Di.PARAIENT
SERVICE I MOP SINK iv_ _ _ _
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING OTHER 1 r2,I°1NS7-5PC--v2A41
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
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 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.
-12: CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
LLI 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 at 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 JP,M`��,,����/E,, (I' A,i o pot�S LICENSE# G5LIQ� SIGNATURE
COMPANYMP NAME I "°f✓r T/c-'►-r'` Ct�TION 0#W ADDRESS PARTNERSHIP
�'�N VLC❑AO
CITY \I 4, "`V V?4 STATE/r') ZIP f TELS
FAX CELL EMAI
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