HomeMy WebLinkAboutBLDP-20-005750 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
q CITY W 491' V v'viC MA DATE • PERMIT# I 40"cri 6-75-6/
JOBSITE ADDRESS ;SAY (ZC OWNER'S NAME 1)1A;gP(C_—
POWNER ADDRESS 15'4 P it Vv'tki moo TEL `` l-4011A I oc FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL,
PRINT
CLEARLY NEW:❑ RENOVATION:t REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES Z FLOOR 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)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
•
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER _
INSURANCE COVERAGE: /
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 1140 ❑
IF YOU CHECKED YES,PLEASE INDICATE TH YPE 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
Ma achusetts General Laws,and that my signature on this permit application waives this requirement.
'1* ^ • CHECK ONE ONLY: OWNER AGENT ❑
SIGNATURE OF 0 ER OR AGENT
I here y certify that all of the details and information I have submitted or entered regarding this application true and accurate to th est of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be i o iance th all Pert' t provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
/SI PLUMBER'S NAME LICENSE# 5 / 6 GNATURE
MP e JP Q CORPORATION 1]# PARTNERSHIP #. C❑#
COMPANY NAME ADDRESS g5- C f '
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CITY _ STATE ZIP 0.9 Co Z 7 TEL .)e 2/72' 4'P c
FAX CELL 78/—7/d - Oho.-7 EMAIL