HomeMy WebLinkAboutBLDP-24-766 /v1 FPr' P6 �c�t,.
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
"a-jiff CITY S /F1-2 M o-,714 MA DATE .7/.5701y PERMIT# QC 0 n-2'+- t.L
`_"' /3/3 r' 14° 52 28- S fa>/� r'11
JOBSITE AOORESS OWNER'S NAME /3/3 117C.49 75(
OWNER ADDRESS / /3ktt7 '2i cc Cv/YJU�1i TELScE-36%-72e7FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW:0 RENOVATION:O. REPLACEMENT:❑ PLANS SUBMITTED:YES❑ NO❑
FIXTURES 7 FLOOR 8SM 1 2 3 4 5 6 7 8 9 10 11 12 t3 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 I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER CAl) oF-1 ,tye
W ,t-s r+
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY❑ BOND 0
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 0
SIGNATURE OF OWNER OR AGENT
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 wiN be In compliance at Pertnen'pro ;n of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME J�r1�1 6# -/kt' LICENSE# /03:2 SIGNATURE
MP175 JP❑ CORPORATION❑# PARTNERSHIP 0# LLC❑#
COMPANY NAME C• C Hitt krk ADDRESS 7Y6 ccn B - /Z/ ra Rci
CITY 4 e 5 STATE ir•14- ZIP 0...a E3's TEL-.6-7)%. o2%•f 6361
FAX CELL EMAIL .5-6 g."/1-c ka L-,v ,L-, cs 041