HomeMy WebLinkAboutBLDP-20-001457 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
I CITY Y11'02-0-40 t,(1-4MA DATE PERMIT# 2n O-CIS yf7
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JOBSITE ADDRESS ''I 67v431 ex:'iR l-vt . OWNERS NAME N
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL D RESIDENTIAL[�
PRINT
CLEARLY NEW: ❑ RENOVATION: REPLACEMENT: ❑ PLANS SUBMI I I ED: YES❑ NO D
FIXTURES 7 FLOOR-+ BS1v1 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 .2
ROOF DRAIN
SHOWER STALL /
SERVICE!MOP SINK TOILET a rRFC- : 1 I
URINAL
WASHING MACHINE CONNECTION '_ a
WATER HEATER ALL TYPES t'
WATER PIPING • r
OTHER
$UILi ING ' EPA
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES/0 ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY 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
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 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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME A!(/ GJOcaS LICENSE#//83'cr 7 SIGNATURE
MP [7JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME /7— lJ)97, s � (4-44 6 ADDRESS iD eQx )
CITY N-4 dri7q47 STATE Pie- frc ZIP D 6F TEL �r )CO 7 (7(F
FAX 3( y j CELL,_? '3/0 7 38 EMAIL t !O (v , / C'L t
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