HomeMy WebLinkAboutBLDP-20-005901 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITYITOWN (3)€5 ( ���k,v):.t MA DATE 3( - '(?0� PERMIT#/ ,lJ/J-G'.-CV yO/
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JOBSITE ADDRESS ?7 plr f ON! . Pit1t( OWNER'S NAME
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT' PLANS SUBMITTED: YES❑ NO[ �
FIXTURES Z FLOOR—+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 j 14
BATHTUB t
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM _
DISHWASHER / _
DRINKING FOUNTAIN t r. �: •
—
FOOD DISPOSER
FLOOR/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 _
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YEW NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
1 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 h a `
M r1
erti nt rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME 770 /1-; ( 5L(j-f rCPA LICENSE# SIGNATURE
MP JP• !!11 CORPORATION 6 / PARTNERSHIP❑# LLC❑#
COMPANY NAME #t9`t'"L HEM<1/6" 't'r 4/ ADDRESS 3 11; 'ff4 'J 2r L 'H
CITY y
- STATE. ZIP c 1 TEL
FAX CELL =7,3S).• 8/1g EMAIL AA/14 l C 1 4 (��1 L ,