HomeMy WebLinkAboutBLDP-24-137 cottage #2 Y Ti i r /co-r-T . -z. Co
MASS�ACHUSETTS UNIFORM APPLICATION FOR A PE IT
IT 0 PERFORM PLUMBING WORK 7
C CITY yly��MbUlt7 MA DATE 2.11 Z C 2 1 QLDQ'VI
1-�.� PE MIT# /,
JOBSITE ADDRESS /� , x OWNERS NAME ` Lir:1-
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL&17.
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT: PLANS SUBMITTED:YES ESI N0 0
FIXTURES 1 FLOOR 8SM 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 1
DEDICATED WATER RECYCLE SYSTEM - -
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN �1
INTERCEPTOR(INTERIOR) R F C _ — it KITCHEN SINK _
LAVATORY • _ [ '
ROOF DRAIN ,
SHOWER STALL
SERVICE I MOP SINK B_UILL ING DEPAR'Mj+r
TOILET „9 '_
URINAL j
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING OTHER _ 1.y 7___ e�I T
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
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
t Massachusetts General Laws,and that my signature on this permit application waives this requirement.
?J CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
LU 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 compliant th all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME/ J (`�Ae,i OPou , LICENSE# G�LIQr , SIGNATURE
MP JP[SL. ` CORPORATIONOR ` 0# PARTNERSHIP❑.#�/7 I t r'/LLC❑#
COMPANY NAME II "�"�✓/`T '�IT ( 4 1- �,{ ADDRESS�I^��'4J7 /C 7 ic
CITY 40f"l� OV?�T STATE!1 Y4 ZIP [ TEL_5.
FAX CELL EMAI WI 1
•i CYrIA