HomeMy WebLinkAboutBLDP-17-001703 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY MA DATE /0 /3 (76 PERMIT# i)9-l7^oo/7oy
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JOBSITE ADDRESS Z� cJ !w•t'- �f/li-0 S'f OWNER'S NAME
OWNER ADDRESS � Li l viw
TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENTS PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1. 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' NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICYt_v 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.
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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 nd a cu e to the best knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complia i a l Perti ent p v' i of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.PLUMBERS NAME A
(42_ 's2"yam` LICENSE# 7607
SIGNATURE
MP❑ JP CORPORATION❑# PARTNERSHIP❑.# ,/ LLC❑#
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COMPANY NAME t W"l� "���-"//�4� f l � 4 ADDRESS 9 ( 4 S 7
CITY (nf ,i 'd134--
STATE rvu- ZIP a Z�`‘d) TEL .SOUy -X
FAX CELL EMAIL
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