HomeMy WebLinkAboutBLDP-24-138 cottage #3 T AT CID T om- '-' 60
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
I ►ZM6U' '}of 2. 1Z ?�C_I = CITY y/� MA DATE MIT _$
JOBSITE ADDRESS ,��� Pia. OWNERS NAME `�^ �-)"
POWNER ADDRESS TEL FAX
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TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL❑ RESIDENTIAL L�
PRINT
CLEARLY NEW:0 RENOVATION: REPLACEMENT:I PLANS SUBMITTED:YES N4O
FIXTURES 7 FLOOR-, BEN 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
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN ( `E 0 E 14_. D 1
_.
INTERCEPTOR(INTERIOR) � - '
KITCHEN SINK _ FE� 12 7074
LAVATORYOOF • L+t}�,i niv L B RJM
ROOF DRAIN . E3U —
SHOWERSTALL - UUU __ _-
SERVICE/MOP SINK
TOILET
URINAL
I WASHING MACHINE CONNECTION _
i WATER HEATER ALL TYPES
WATER PIPING - c y�q ,�y� g - -
OTHER I.Y2/4Als7-- ,,S C eiVVt,t - _
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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 Elt<ci
IF YOU CHECKED YES,PLEASE INDICATE THE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY 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
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Z. CHECK ONE ONLY: OWNER❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
L:l 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 JP LLL___MMM,///E,,, ('p,r A,d oPov 1 O LICENSE# G� SIGNATURE
MP COMPANY NAME I 'v t✓r T�„/7't CORPORATION_ # PAADDRESS
0# LLC 0#
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CITY / 4gvtiov r�"� STATE M/J ZIP ( TEL
FAX CELL
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