HomeMy WebLinkAboutBLDP-20-003828 RI',Are ci Y E6
s MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
U; CITY NPAUv1 c T MA DATE i C' PERMIT# -G0✓SAS
JOBSITE ADDRESS ]Z i)DD H E ;��y LiTNNE-- OWNER'S NAME 0 12)L— ZA L"\-}t T S
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL E EDUCATIONAL D RESIDENTIAL 0----------‘
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 ~_ _______I
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) i
KITCHEN SINK / i `
I LAVATORY / J '
ROOF DRAIN
SHOWER STALL / / '# . 1U"
• SERVICE/MOP SINK
TOILET / i
i URINAL
. WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
1
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO E
i
IF YOU CHECKED YES, PLEASE INDICATE THE TYP 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
I` 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 a true nil a to to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in ' all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME be __E. ,c_. LE.C. .,`L LICENSE# Z,coCZ2_ SIGNATURE
MP ❑ JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME LE. (C_-.; l'i_U,^feS.;Nl C., ADDRESS t) C' f' ' ` )n b
CITY l-o,e_e_s-rtAct_ STATE T'-''`-) ZIP Cal,`f`/ TEL L CZ.. 7e-- )
cr
FAX CELL EMAIL L E-C_L_ 6)FJC K.--CC A c C.c`r')
F-
0
z
z
o .
P
0
Z
a
z
0
z
.4 a)❑
z >-
O F- G]
CO C F-
W O .
- a xt Z
w r
to Ce
O ¢ a
Ocn
>
-(- w Z
to ,
. c
- 0
z Q .
0
tL
et_
Q feb-
Co W
H L .
W
k
0
z
z
0
H
a
z
Zco
�
z
p7
iiik ta
a
y
0