HomeMy WebLinkAboutBLDP-24-604 #B /MP.' Pmeece e
12:4, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
_n): CITY YOrl'1 Oi—i'1 MA •DATE j 7/'4/Z' I PERMIT# C. 0�- z - to"_
JOBSITEADDRESS 09 Pine (:rcJe 12d OWNER'S NAMEI_ YfSnfevr Avert.=t:.hD
p OWNER ADDRESS maI IFAX I
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[ J
PRINT
CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:ID PLANS SUBMITTED: YES 0 NOD
FIXTURES 7 FLOOR-0 BSM 1 2 3 4 5 6 7 8 11 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE ' •
DEDICATED SPECIAL WASTE SYSTEM ° '
DEDICATED GAS/OIL/SAND SYSTEM RR !
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM •
DEDICATED WATER RECYCLE SYSTE7►I
DISHWASHER
DRINKING FOUNTAIN 11111.111:ilaillilgoini
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FOOD DISPOSER �:��)�:.�I�PM���
FLOOR/AREA DRAIN •NTERCEPTOR ANTERIOR 111111,11111111 ;� I�Willi
KITC SINK M11(111N1 BEIM NM M INK:imp'um iim Am'I=llINKMIMI 1111111;
SHOWER STAU.
SERVICE •- I....air_TOILET .
URINAL .
WASHING MACHINE CONNECTION , ' . 1 ., , . IF , ' ,
WATER HEATER ALL'TYPES 4 "
WATER PIPING
OTHER I 11111111 �
�annatiaaRannan. iR n
• INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES❑-NO D.
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY a 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT
SIGNATURE OF OWNER OR AGENT •
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.
PLUMBER'S NAME I_J-e/14 l 5, 4-/ 9/`_�C1-e. LICENSE# ' ?''G'1 I SIGNA ,
MP Er JP El CORPORATION 3 ;3`? IPARTNERSHIP❑# LLC❑#F
COMPANY NAME jl//, )//17`f Pie Il , C ADDRESS //( � P ,—
CnYl/:. a,e,n i�r k I STATE r'17,1 1 ZIP !1 J 6'2 I TEL �74/% --[5,.
to l I II inCi I I f I COUAII J