HomeMy WebLinkAboutBLDP-20-000076 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY • i CJ'✓ MA DATE /J / / PERMIT#/i4D/2'0`O0�7�
JOB SITE ADDRESS Sh���, �kr re-, OWNERS NAME
OWNER ADDRESS J C1 )1;-e-- TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT:' PLANS SUBMITTED: YES❑ NOO
FIXTURES J. FLOOR-4 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
i SERVICE/MOP SINK
TOILET
URINAL _
i WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES J
' WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YE1 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
1` Massachusetts General Laws, and that my signature on this permit application waives this requirement.
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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 tru nd accurate to • e b t of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co lance ith all r-rline provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. f"
PLUMBER'S NAME LICENSE#?MI/ . SIGNATURE
MP ❑ JPNJ CORPORhT101 # PARTN SHIP❑.# LLC❑#
COMPANY NAME /IT ADDRESS > nay /✓4')` I .S
CITY W �l G r l f STATE ZIP S /
TEL Q, -H-Y ? Yci.J
FAX CELL Sq/de e EMAIL /0 CPe j A% / of Ina)( (o 1A '
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