HomeMy WebLinkAboutBLDP-18-004025 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
14.-12 .ari
a CITY MA DATE O/ /r PERIvI(T# ��p I$Y34 clay'
JOB ITE ADDRESS/ OWNER'S NAME I6A9/Ir / 2/001 2O
r P OWNER ADDRESS / 1 _ EL FAX
TYPE OR OCCUPANCY TYPE COMM CIAL EDUCATIONAL ❑ RESIDENTIAL
PRINT �-,/
CLEARLY NEW: ❑ RENOVATION: ) REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO.[�
FIXTURES 7- FLOOR--I BSIA 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
_
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) T J
KITCHEN SINK -
I LAVATORY
ROOF DRAIN D
SHOWER STALL "'"` --,.---•-
•
SERVICE/MOP SINK
' TOILET i�+� ( f [�1�
URINAL L_.e
WASHING MACHINE CONNECTION ;IL
I F. �.I .
WATER HEATER ALL TYPES r• �_ ?�
WATER PIPING
OTHER 1
Sr jr r kuba.k, 1
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES - NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND El
I OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
i' Massachusetts General Laws, and that my signature on this permit application waives this requirement.
°� CHECK ONE ONLY: OWNER [I] GENT ❑
SIGNATURE OF OWNER OR AGENT
• I hereby certify that all of the details and information I have submitted or entered regarding this application ar: : and a urate to the b knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in.. . ance h all P mine ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME LICENSE# 00?_,. /,//
MP [ jV JP ❑ C RPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME ( ?U(J J)/L� /�
/ ADDRESS / 7� O/'Vl;e7 'Cif
CITY 1 41_).(-A r ST ZIP o,695 TEL 6O, y3 571
FAX CELL 50, j / ,3 EMAIL ACES /OP qoorAv--Aa /'
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