HomeMy WebLinkAboutBLDP&G-20-003645 MASSACHUSETTS UNIFORM APPLICATION FOR APERMIT T0 PERFORM PLUMBING WORK
��.
CITY WN LATE ro —�"��PERM�#
v
JO8SITEADDRESS �^l/ OWN2FYSNAME,
�ODHEGG TEJ���'��v �FAX U
OWNER ADDRESS -- - --'-- -- - - — — '— � ~.� ~ *�u - ' - -- -�
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL El RESIDENTIAL��
PRINT
CLEARLY NEW:� �N��0N�0 �PU0E�E�'� PLANS NO[]
~~ .�� .�� . �� ��
F(XTURE3'l FLOOR— oSM 1 e x * 5 V 7 o o 10 11 u 13 w
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER F,
DRINKING FOUNTAIN
FOOD DISPOSER '-f! —J
FLOOR/AREA DRAIN
INTERCEPTOR.ONTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
Al
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO E]
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY[,, OTHER TYPE DF INDEMNITY E3 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 an this permit application waives this requirement,
'
CH'CKwNEONLY; ^ NER �� AGENT [l
8|GNATUREOF{AWNERORAGENT
1 hereby certify regarding this onpom,o'no, ou-unuoouu� mme�m mmvxnmwoono
plumbing m �
°""".^`a./ wn �nn/nnoan m installations performed fo
r m in ^mp|' on `om' ontp 'vision ovthe
Massachusetts State Plumbing Code and Chapter 14cvr the General Laws- AC
PLUMBER'S NAME Dennis M.Devine �L|CENSE# 11741 R.
MP[j] JP CORPORAT|ON[0# 2931 `UL' ��*_____ /
COMPANY NAME.Devine Plumbioo&Heating,|n�.__ _ _ _ ADDRESS 8JamSehuotiamDhve Unit_23
CRY _ UGTATE\ �A2]P 02563 _ ._ � TEL SO8880�OO2
FAX , CELL EMAIL |
_ _ __--_--__— ' ' -- _ -