HomeMy WebLinkAboutBLDP-19-001981 /70
r.._ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 1
`_==1=e CITY `1444-vaS-Li'f MA DATE (0-6"S"ac17 PERMIT#/*/)r%9-00/71/
JOBSITE ADDRESS CO- GLCAULhwc) Wjc"f OWNERS NAME eit e-F
POWNER ADDRESS TEL 9A-7B4-b)r-c- FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIALX
PRINT
CLEARLY NEW:❑ RENOVATION:X. REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO 0
FIXTURES 1. 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 I
DEDICATED WATER RECYCLE SYSTEM
(wl DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
I LAVATORY '3• a •
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK I
J.
TOILET
a 1 _
�j URINAL _
9 WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
j
a 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 TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW T
UABIUTY INSURANCE POUCY`,[J 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
r Massachusetts General Laws,and that my signature on this permit application waives this requirement
'Z CHECK ONE ONLY: OWNER❑ AGENT 0
SIGNATURE OF OWNER OR AGENT
L1.1 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.
21CirAlrg —
PLUMBERS NAME LICENSE# n� f'yt
SIGNATURE
MP 0 JP CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME f'L?f 5l.r6,1a-C ADDRESS f O�'O W(^ � n (7-.
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CITY WEST (�I�O S-t4 IS(L STATE MAT ZIP 8�l4(YR rr-- II--TEL Sod- 3 !"»�P7
FAX CELL EMAIL ( 44kktckc Jh4rrrcon
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