HomeMy WebLinkAboutBLDP-20-004549 •
- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
WC CITY St \ICILT(1)0/1ti MA DATE 02/0'7-02 0 PERMIT# 4 0-60`:6574
JOBSITE ADDRESS 461 TG4 RBI OWNER'S NAME "Ph‘ 11 lie _Roceo,„
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OWNER ADDRESS 7a (qt1 ��LS� � risti TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
, CLEARLY NEW: E( RENOVATION:$ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑,
FIXTURES•1 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 I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY i •
ROOF DRAIN
SHOWER STALL
I SERVICE/MOP SINK
TOILET ! _ T
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 Chi 142 YE-94 IO ❑ '
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BEL011114 4 6
LIABILITY INSURANCE POLICY ft. OTHER TYPE OF INDEMNITY ❑ BOND ❑ V —
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage requ re '14 Ehap�dv Il ENT
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 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 with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME LICENSE#QL34393 SIGNATURE
MP ❑ JP, CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME R Ael STATE n ADDRESS 3r a r ,tc_dt L .
CITY �' KL�'ik ZIP OZ TEL 7 7�'-30•32S F?e M f{
FAX CELL EMAIL
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