HomeMy WebLinkAboutBLDP-18-003890 _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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411 yam,/ CITY 5 -7 , e/fy')Qj/7s MA DATE 110P i/!P 1 PERMIT# P 48''A5r.I WO
JOBSITE ADDRESS `j 76604.) i- i/( ,611p OWNER'S NAME ,7 p7&c 4/ .e)- 4/
POWNER ADDRESS i TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL . EDUCATIONAL RESIDENTIAL a I Do•Do
PRINT _ _
CLEARLY NEW: RENOVATION:_,._ REPLACEMENT:' PLANS SUBMITTED: YES�I NO:
FIXTURES Z FLOOR—, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB ) ;7-' ' V; y IJ ,
CROSS CONNECTION DEVICE '' I
DEDICATED SPECIAL WASTE SYSTEM i _ ,! Y 1
DEDICATED GAS/OIL/SAND SYSTEM _' li ,i 1 .1 1 I
DEDICATED GREASE SYSTEM '; i ' I' -
DEDICATED GRAY WATER SYSTEM ! �' ,
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DEDICATED WATER RECYCLE SYSTEM 11i j i
DISHWASHER 1
DRINKING FOUNTAIN , , , _ 3'
FOOD DISPOSER t �I —.
FLOOR/AREA DRAIN '
INTERCEPTOR(INTERIOR)
KITCHEN SINK 1 { ' t
LAVATORY i L 1 j '! y ,i ________„ , _
ROOF DRAIN
SHOWER STALL i ' ,1 ! J I ;
SERVICE/MOP SINK '' '
TOILET I
URINAL J
WASHING MACHINE CONNECTION i y
WATER HEATER ALL TYPES ME:
WATER PIPING i
OTHER ' 1 I'
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL h.142. YES kr NO _i
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW Ark?'i � /j.T
LIABILITY INSURANCE POLICY V OTHER TYPE OF INDEMNITY _ BOND Ti L.
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER , AGENT I
SIGNATURE OF OWNER OR AGENT
I hereby certify that at 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 corn ' 'h all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME l I AT , b bek r d _ ,LICENSE# II)1'77 SIGNATURE
MP✓ JP_j CORPORATION[ # _v PARTNERSHIP #1 LLC #
COMPANY NAME C ,,is j- iirt ADDRESS 5'
CITY 3-, "el1s/vI f _ j STATE 1'y - ZIP Q ;Z A/0 TEL II? , jiy Z 2 Z I' 4
FAX i CELL i EMAIL I g 'hS' yr "
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