HomeMy WebLinkAboutBLDP-19-000406 rTI—� CITY SSACHUSETTS UNIFORM APP TMA At FORPERMIT TO PERFORM RMITPLUMBING WORK �0�
I —5. 7
JOB RE ADDRESS/� ( OWNER'S NAME !O C �J
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL❑
PRINT
CI FARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMI I ItU:YES❑ NO
FIXTURES 2 FLOOR—, BSM 1 2 3 4 5 6 7 6 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM _ _I
DEDICATED GAS/OIL/SAND SYSTEM T
DEDICATED GREASE SYSTEM _
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER E bI/� •
DRINKING FOUNTAIN Y�rf' 4 ---1/6/
FOOD DISPOSER
FLOOR!AREA DRAIN �_
INTERCEPTOR(INTERIOR)
KITCHEN SINK t l
LAVATORY
ROOF DRAIN _
SHOWER STALL - .
SERVICE I MOP SINK
TOILET
URINAL -
. i WASHING MACHINE CONNECTION /
WATER HEATER ALL TYPES
WATER PIPING
OTHER
y _
INSURANCE COVERAGE:
I have a current liabiny insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ' N0 0
IF YOU CHECKED YES,PI EASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILTTY INSURANCE POLICY I OTHER TYPEOF 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 requirement
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this applicaio' .-. a and accurate to my knowledge
and that all plumbing work and installations performed under the permit issued for this application will.- ... p ce withpII P t vision of the
Massachusetts State PlumbingumT Code and Chapter 142 of the General Laws.
,_�
PLUMBERS� NAME\ if /2 6,OC)C— LICENSE#/ J f' TU
MPUX JP V/ ORPORATION❑# PARTNERSHIP 0# LLC1 y/sv
COMPANY/N/AM c T �ORESS
CITY J Y J/(' AT ZIP OA,J // TEL�V /c���0c�3h
5
FAX CELLS4- 2/7 53 EMAIL (P C, `l p� CYYYI(ific,71,4/!'
Co
H
0
.47
H
U
Co
Z
2n
4 >
o C
H
L1.1 o
= r
[n
O LLI
w
12,1
`r' -
o L
o
U
1.1
a_
F--1 LL
UD
L--rq
0
C
U
Co
C-7