HomeMy WebLinkAboutBLDP-24-139 cottage #4 Y- L Th I -T C0-TT
MASyS�ACHUSETTS'UNIFORM APPLICATION FOR A PERMIT O PERFORM PLUMBING WORK
_ 3_ CITY yr"CRMou-11 MA DATE 2. r�
I���2�� PE MIT ?LQP 21-I}9
JOBSITE ADDRESS 2, �Y� per_ OWNER'S NAME 1 ,...,T6C}/ -�-
POWNER ADDRESS TEL FAX ��
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:V REPLACEMENT: PLANS SUBMITTED: YES LTV NO 0
FIXTURES 1 FLOOR-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE —
DEDICATED SPECIAL WASTE SYSTEM r —,
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM -
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN K 17 C i V f'D- 1
INTERCEPTOR(INTERIOR) -- -4--- -
KITCHEN SINK - -
LAVATORY •
fi 12 2O24
ROOF DRAIN — -
SHOWER STALL 8u LDiNb ut-A,.ns r r i
•
SERVICE/MOP SINK
TOILET H
URINAL
j WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING V y��.
OTHER 1,f J IQ 7- eeizmi T '
_
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES f4r.0
IF YOU CHECKED YES,PLEASE INDICATE THE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY 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.
CHECK ONE ONLY: OWNER 0 AGENT❑
Z SIGNATURE OF OWNER OR AGENT
k-ll I hereby certify that all of the details and information I have submitted or entered regarding this application am 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 ' all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME t)(�Ar gr you � LICENSE# G5L jq SIGNATURE
MP� JP LEI L.{�,/�{/J� ` CORPORATION❑# PARTNERSHIPJ A❑.I#�/ 1,t,1/LLC❑#
COMPANY NAME IIq 64 `- i ( 4-17 ADDRESS 2,6 -ICJ G�tO Z
CITY ! 4 40V-rt+ STATEMit) ZIP ( TEL-5
FAX CELL EMAI
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