HomeMy WebLinkAboutBLDP-20-003262 '� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
{=a CITY QAv-nA,Duel MA DATE LI- ^ 5—^ 1 et PERMIT# ''.J'i--‹' ( T' ,:,
%, JOBSITE ADDRESS I I (? EVec/Gr✓LLB OWNER'S NAME ('1✓S le--'C I 1.1
POWNER ADDRESS I ( Le Ccr~ yv tc,-, TEL CC 11 ' /g Z- Dbi'vtAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0/
PRINT
CLEARLY NEW:D. RENOVATION: REPLACEMENT:❑ PLANS SUBMI I I ED: YES❑ NO❑
FIXTURES 7 FLOOR-I BSIv1 1 2 3 4 5 6 7 B 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 I
ROOF DRAIN �n
SHOWER STALL ' I r ' '.*1 QL- O6
•
SERVICE/MOP SINK
TOILET I
URINAL
. i WASHING MACHINE CONNECTION I •�
WATER HEATER ALL TYPES _ _
WATER PIPING
OTHER _ ' . i ' _
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Id NO 0
IF YOU CHECKED YES,PLEASE INDICATE TH PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY 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
II Massachusetts General Laws,and that my signature on this permit application waives this requirement.
rn CHECK ONE ONLY: OWNER 0 AGENT ❑
SIGNATURE OF OWNER OR AGENT
t 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 complian ertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# 3 o 3(3 J SIGNATURE
MP❑ JP CORPORATION 0# PARTNERSHIP 0.# LLC 0#
COMPANY NAME eav� 1 ( ho' ADDRESS -949 9 f - " l"'-, \ t—
CITY Q U t ''1 C i STATE lx-(4 ZIP GZ C 6`j' TEL c.[17 '()4 '0-'
FAX CELL EMAIL_rica_V t pv'-'6'`h 7 p q yv'-ct c l ' 6 r
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