HomeMy WebLinkAboutBLDP-24-168 MASSACHUSETTS UNIFORM APPLICATION FORA PE IT TO PERFORM PLUMBING WORK
�_ CITY C rM0 t D 0.2 L' ��? F it MA DATE c v PERMIT# z I(c'8
JOBSITEADDRESS 7 (LZwyec 1'1c P OWNER'S NAME oI,✓f,S IYJ/T7/.11 J//Llo/�
P OWNER ADDRESS Ea -1-.- c 1`O 6 4
TEL / 22--13 Z�fFAX_
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL ti"
PRINT
CLEARLY NEW II RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES®, NO 0
FIXTURES 1 FLOOR-I BSM 1 2 3 4 5 6 7 6 9 10 11 12 13 14
BATHTUB 1
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM -
DEDICATED WATER RECYCLE SYSTEM _ _L—
DISHWASHER / •
DRINKING FOUNTAIN --
FOOD DISPOSER
FLOOR/AREA DRAIN 1 -
INTERCEPTOR(INTERIOR) — -
KITCHEN SINK / t a w -
LAVATORY Z t , -
ROOF DRAIN
SHOWER STALL / ..1 �I 1 . cvY'I __I
SERVICE I MOP SINK 1
TOILET , l 1_ —''' i I -
URINAL _ .-__ _J `y
j WASHING MACHINE CONNECTION /'
WATER HEATER ALL TYPES /
WATER PIPING
OTHERr
-
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES(kl NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POUCY ® 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
1 Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
LI.I I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and Installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. fie,
86 ��\
PLUMBER'S NAME M c8r, // Iil CGZ4et LICENSE# / SIGNATURE
MP❑ JP fp n CORPORATION 0# PARTNERSHIP 0.# LLCCj❑� #
COMPANY AME t! Vr� (,�Orl kP+it ADDRESS 7 ,ri 4t L1_/4tre, i e
CITY I 61 i'N fs t S STATE i4A ZIP 0�Z 0/ TEL 77 Y `e/p jdzZ
FAX CELL EMAIL `51-1 n'i W -oM(...-Ar l G11-t' 05,wy4,(6L,
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