HomeMy WebLinkAboutBLDP-20-004391 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
LL / CITY d MA DATE i 1 D PERMIT# �/�-0d�d 9'3`/
JOBS( E ADDRESS Ai is?': f�1� ,2 - OWNERS NAME%�.51C4 5C. :.Te>
OWNER ADDRESS ''-7.4 7 SIP/ FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[�—
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR-F 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) c _ mV ,
iL
KITCHEN S
LAVATORY
INK /
ROOF DRAIN �p
..4eke4
SHOWER STALL 4/0v_ _
• SERVICE/MOP SINKjFARTh1N
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
III I•
NSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO ❑
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY lil/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 ue an curate to t best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be i o with all Pe nt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME LICENSE#16 eleY,}' J- SI TURE
MP ❑ JP CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME Cd/ /V ' �k''17 ADDRESS r3 1Pf�'
CITY )lid® STATE / ZIP A TEL O/‘,... '2"53- a
FAX CELJ' % EMAIL / o' C /6
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