HomeMy WebLinkAboutBLDP-23-11894 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
— cITY a1t� a"� d3 -
= ' � MA DATE �/ � PERM/IT � OP'ZT —//p9�j
— JOBSITE ADDRESS /71a hi 5( OWNER'S NAME 42447 4,41)7(r.(/
P OWNER ADDRESS TEL FAX.
TYPE OR OCCUPANCY TYPE COMM CIAL❑ EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED:YES 0 NO❑
FIXTURES 1 FLOOR—. BSM 1 2 3 4 5 6 7 B' 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 _
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER •
DRINKING FOUNTAIN _ _
FOOD DISPOSER _ _
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) '
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL / _
SERVICE I MOP SINK / -
TOILET
URINAL _ _
WASHING MACHINE CONNECTION _
WATER HEATER ALL TYPES
WATER PIPING _ _
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO 0
IF YOU CHECKED YES.PLEASE INDICATE THE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY INSURANCE POUCY 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 requiremenL
CHECK ONE ONLY: OWNER❑ AGENT❑
SIGNATURE OF OWNER OR AGENT
LLI I hereby certify that all of the details and information I have submitted or entered regarding this application am 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 �c appliance with all P$n t provision of the
Massachusetts State Plumbf Code andrChap 142 of the General Laws. p /i" _ ._�/
PLUMB 'SNAME )OP WI ga LICENSE#t5°r .M WSIGNATURE
MP JP❑ 1f CORPORATION 0# PARTNERSHIP❑# LLC 0#
COMPANY NAME(o D 5 firYt�I/15 1- 4271 ADDRESS`S`�1J— Ot0' U55 (lug R2
CITY °CPA r 5 STATE fl ZIP o.'jt TEL/ -/
FAX CELL >7'f SS3 6 /�I EMAIL vtt I Ir�0(,r0 , dm/ ,t•J/m
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