HomeMy WebLinkAboutBLDG-23-9520 — MASSACHUSETTSS UNIFORM/ APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
j CITY / U i`%/ (T MA DATE 9 '2<—/'
PERMIT# gLD4; Z It-qy
JOBSITE ADDRESS 73 G'tf"67TiAI / )N5' OWNER'S NAME a()CA/0 0 L
POWNER ADDRESS TEL.�GV-!6 --)75 33 FAX_
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:lY/ PLANS SUBMITTED:YES 0 NO❑
FIXTURES 1 FLOOR—, 6SM 1 2 3 4 5 6 7 6 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 T
INTERCEPTOR(INTERIOR)
KITCHEN SINK 1
LAVATORY r
ROOF DRAIN J —
SHOWER STALL 4 E E V E B
SERVICE 1 MOP SINK T __, -
TOILET SEP 2 7 2023
URINAL
i WASHING MACHINE CONNECTION - N
WATER HEATER ALL TYPES r o ILDIW"u -A uTkn-NT ul
WATER PIPING _ f`
OTHER
6','r) .6(3- 'i�
6q-s i (Ciu c
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YESI O 0
IF YOU CHECKED YES,PLEASE INDICATE E 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.CHECK ONE ONLY: OWNER❑ AGENT❑
SIGNATURE OF OWNER OR AGENT
LU I hereby certify that all of the details and information I have submitted or entered regarding this application am true and accurate to the best of my knowledge
and that at plumbing wet and Installations performed under the permit Issued for this application will be in compliance wi all ertinant rovision th
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE#9 5Ej SIGNATURE
MP❑ JP[� CORPORATION 0 It PARTNERSHIP❑# LLC
COMPANY NAME i\11l.4Q..CJC 0(jina‘riN7 ADDRESS (\\INf (J
CITY P\~)t .X1S-1"t � � STATE'11 ZIP C �� TEL
17,J—y
FAX CELL [ 1 34 7`1 EMAIL < l Q� 6 Yri �G