HomeMy WebLinkAboutBLDP-19-005524 ST —
MASSACHUSETTS UNIFORM APPLICATION FOR A�PERMIT TO PERFORM PLUMBING WORK a-
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CITY SO. 7/�7Qtt rOt/fiC MA DATE ,�/9/7 PERMIT# L� I'�5C.X7
JOBSITE ADDRESS / CA en S OWNERS NAME CA.(tR y
POWNER ADDRESS TEL f TEL FAX_
TYPE OR OCCUPANCY E COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL lld----
PRINT
CLEARLY NEW: RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES NO❑
FIXTURES 1. FLOOR—. 9SM 1 2 3 4 5 6 7 B 9 10 11 12 13 14
BATHTUB l _
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) R-E C-E Ft' El KITCHEN SINK
j LAVATORY ai}
ROOF DRAIN j -MAR 2-8-AIM I
I SHOWER STALL
I SERVICE/MOP SINK
I TOILET / ) -uirvk ..crs11-11Mt_�v'
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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 THETYP OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY 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 requirement
-7-: CHECK ONE ONLY: OWNER❑ AGENT 11
SIGNATURE OF OWNER OR AGENT
Ltl 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 the
Massachusetts State Plumbing Code Chapter
1 of the General Laws.s.
PLUMBER'S AME 6 / &Dc'a!5 �e.rI y!'TE
,� LICENSE#/��$7 SIGNATURE
MP JP 0 CORPORATION Ly4� PARTNERSHIP
# LLC❑#
COMPANY NAME l5 DAf,D S /v7(�/6/"ADDRESS /90/(JZ�SC ? Z
CITY (Al •�py¢j?�z/ ESTATE®G��il ZIP40,2461 TEL 6�1� 1 7�2 3
FAX ` l 2 vim5 CELL 36 / 30._1(1 EMAIL�,L/7).J/C5 L`o � CbYt/I
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