HomeMy WebLinkAboutBLDP-17-001601 x'w"��xO ° �� ��^�� "
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MASSACHUSETTSWNUFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY ^�^ �A OAJ� PE0N|T#��`���-���~«�� -
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~~' JD8SITEADDRESS OWNER'S NAME
OWNER ADDRESS _ _ _ _ TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL| ! EDUCAT0NAL E3 RESIDENTIAL��
PRINT
CLEARLY NBN:Lj RENOVATION:[l REPLACEMENT: PLANS SUBMITTED: YES Fj NQ[j
F|XTURES'l FLOOR-~ nSw 1 2 a 4 s G 7 8 9 10 11 12 15 14
BATHTUB
CROSS CONNECTION DEVICE A--
DEDICATED SPECIAL WASTE SYSTEM
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DEDICATED GAS0|L/SANDSYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM �NN�ikN�0�L
DISHWASHER 1
DRINKING FOUNTAIN ij
FOOD DISPOSER
FLOOR/AREA DRAINalso:
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN QL- I
SHOWER STALL
SERVICE/MOP SINK WX
URINAL
TOILET
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WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
U,
OTHER
INSURANCE COVERAGE:
|have a current liability insurance policy orits substantial equivalent which meets the requirements ofKGL Ch.142. YES0 NO N
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY
- OTHER TYPE 0F INDEMNITY |j BONOEj
OWNER'S INSURANCE WAIVER: |am aware that the licensee does not have the insurance coverage required by Chapter 14%ufthe
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER �l AGENT Ej
SIGNATURE OF OWNER ORAGENT
|xarebr certify that all o,the details and information/have submitted or entered regarding this application are true mmovmum��m � mw o ��oymymncwoe
and m�onp/ummngwnmand im�u:ou pe
rformed th
e m mm issued for m ma �:~ ' m�hoopamnen »mwnwnorme
maxoochunounn��p/ummnnCode and oxap�,1*ommeoona�|Laws. �N��� '
PLUMBER'�NAME � `� � , ��� � VU�NSE# | ��O �- -� �� �G��
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�p� �D CORPORATION ��E�|P�# . �[�
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COMPANY NAME "�ADDRESS U �
CITY . U�. \1r���*4/ _ _ � E ��,� �p _ �����7.�� TEL /60El�7��^
FAX 6^*^!nv'�-&� CELL
EMAIL
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