HomeMy WebLinkAboutBLDP-17-001176 •
1 p • RcH
.- ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO-PERFORM PLUMBING WORK
=d { CITY \kCkC'C`Ool.)-C MA DATE 7c Z25 6 PERMIT# %7-09%1'4'
..�0 . JOBSITE ADDRESS-23L ?\ cv <S*cep OWNER'S NAME` CZOC\C—�,
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Z •
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:{it PLANS SUBMITTED: YES ❑ NO❑ ( 0
•
1XTURES-1 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 '11 ' 12 13 14 -
,ATHTUB .
',ROSS CONNECTION DEVICE
)EDICATED SPECIAL WASTE SYSTEM
)EDICATED GASIOIUSAND SYSTEM - .
)EDICATED GREASE SYSTEM 1 (
)EDICATED GRAY WATER SYSTEM •
1EDCCATED WATER RECYCLE SYSTEM •
)ISHWASHER
)RINKING FOUNTAIN • (1
=00D DISPOSER -
LOOR 1 AREA DRAIN • - �i
NTERCEPTOR(INTERIOR) . • v
CITCHI=N SINK • P
. .. _ -
AVATORY -
•
ROOF DRAIN .
;HWWER STALL . N
SERVICE/MOP SINK •
TOILET
JRINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES • ( . . il.
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 I4 NO.❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW .
0
- 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 3
Massachusetts General Laws;and that my signature on this permit application waives this requirement.
• CHECK ONE ONLY: OWNER ❑ AGENT D.
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 compile ith all Perti provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME C a r l S. P'i ed e- 1 LICENSE# `z?".. y( SI ATURE -
MPia JP❑ . CORPORATION ❑# PARTNERSHIP❑# LLC❑#
•
COMPANY NAME C-Q r t F. • R, cd C r i t Son ADDRESS . "7 7 S .M c, I'm S t-ce +-
•
CITY O S fi e r v i l l e . - STATE M A ZIP O a Co 5 5 'TEL 5O SS- L 9-- Co 3Co 5
FAX CELL EMAIL