HomeMy WebLinkAboutBLDP-24-504 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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7f'� CITY MA DATE3 PERMIT# rY ° 'ZI— 5-6`I
JOBSITE ADDRESS (17 (eAr it/ OWNER'S NAME at) Cfj 12-190/a _.
POWNER ADDRESS .136 C EA/ it- 3 TEL,....�L ,; 3 i FAX I
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL X
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: ► PLANS SUBMITTED: YES NO Pc
FIXTURES Z FLOOR-. 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
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DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN _
FOOD DISPOSER _
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY • _ _
ROOF DRAIN
SHOWER STALL RECEIVE. t
SERVICE!MOP SINK "�
LET
URINAL ' MAY 2 3 202,4
WASHING MACHINE CONNECTION
— L._ __i
WATER HEATER ALL TYPES
E3UILDING ID
WATER PIPING 5y
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO x,
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachus s General Laws nddythat my signature on this permit application waives this requirement.
rc 7'lrl�l1 ' CHECK
- �• ( � C ONE ONLY: OWNER AGENT
SIGNATURE OF OWWR OR A ENT
I hereby certify that all of the details and fnformation I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all pl mbing work and installations performed under the permit issued for this application will be in mpliance wit all P rtiRent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME rium f',`j :I. 1 O1.14.5 LICENSE# ivC,5 i%r IGNATURE
MP , . JP CORPORATION # PARTNERSHIP # LLC #
COMPANY NAME M t rr1t�. _J Ho Lf 1,!.3 ADDRESS 5 ill C ` i6 J / J-
CITY 6 1 � �I G/I STATE l► ZIP Gry, ,✓0 TEL ► '7'7`T �i C 14'1 J
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FAX CELL EMAIL . 7 it1-1 5 b 62 I C.14)LjJ 1 C