HomeMy WebLinkAboutBLDP-19-005498 __
6 F r iRf C
MASSACHUSETTS UNIFORM APPLICATION FOR PEERI)�ITG�TO PERFORM PLUMBING
�WORK
' CITY Yr�1 T�I V�'�1 Q4 MA DATE J/l/// / PERM/Rf# /" 9-aXl ,
JOBSITE ADDRESS y I7 14) �\ / OWNER'S NAME ///G/
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL L
PRINT ^ /
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO E2'
FIXTURES 7 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
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER / '
DRINKING FOUNTAIN
FOOD DISPOSER `V-E Er
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK I AR 200
LAVATORY '
ROOF DRAIN I_ - -p1/ mF
SHOWER STALL
SERVICE/MOP SINK '
TOILET '
URINAL '
WASHING MACHINE CONNECTION /
WATER HEATER ALL TYPES I
WATER PIPING
OTHER
INSURANCE COVERAGE: /
I have a current liability insurance policy or As substantial equivalent which meets the requirements of MGL Ch.142. YES efNO 0
IF YOU CHECKED YES,PI EASE INDICATE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY 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 apQBcation waives this requirement.
2 CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
L:l I hereby certify that all of the details and information I have submitted or entered regarding this application,-btu:an.accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application WE be`%m. 'i all Pertinent provision of the
Massachusetts State Plumbing Ctpde and Cmapter 142 of the General Laws. / i•�
PLUMBER'S NAME /1 Y1J1 oGr�tt LICENSE#AP/2 / SIGNATURE
MP 2/ JP❑ CORPORATION/� 0# PARTNERSHIP 0## e L LC 0#
COMP NAME Is/ �' �I� Y'r ADDRESS �7 eI�//rn
CITY ti ein STATE 4 ZIP 2.a' ,57 TEL
_ 2,gi. ,
FAX CELL EMAIL ' i",.+
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