HomeMy WebLinkAboutBLDP-16-003872 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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� °- r9 MA DATE V9A, PERMIT# jf'1 4 9 la-
JOBSITE ADDRESS ;2,3 5 ('271 1 t�V t�.�,7 OWNER'S NAME 9ZCZ u Rent' •5 1-C,L
POWNER ADDRESS _ TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL-
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT:' PLANS SUBMITTED: YES ' NO`
FIXTURES 7 FLOOR—. BSM 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)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL I
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES f
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES f NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND
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
I hereby certify that all of the details and information I have submitted or entered regarding this application are true a 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 com i ce wit a Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. f'/� I
PLUMBER'S NAME ken duarte LICENSE# 11012 / b4 SIGNATURE
MP JP CORPORATION # 3541 PARTNERSHIP—#' LLC #
COMPANY NAME duarte plumbing Inc ADDRESS 37 collins ave
CITY Centerville STATE ma ZIP 02632 TEL 508-250-2763
FAX 508-775-9135 CELL EMAIL kenduarte37@hotmail.com
UC �T
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES