HomeMy WebLinkAboutBLDP-18-006655 •
MASSACHUSETTS UNIFORM APPLICATION FOR A ERMIT 0 PERFORM PLUMBING WORK
' CITY_� y G�� MA DATE j Z'Z PERMIT# D /� dotJ;
JOBSITE ADDRESS 3 7 �� ( ' 1 4:A S' 4-/9 VNER'S NAME [L,. C1'1 c^r 1"IL) ttt7'
OWNER ADDRESS TEL 21.E FAX
FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[
PRINT
CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7. FLOOR—F 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 _ 2
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[a' NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY g. 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
11 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 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 r1�42 of the General Laws.PLUMBER'S NAME t\'1 l u-e L C -11 C942 LICENSE# /-f?(�'F./ SIGNATURE
MP [t JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME'l C� v r1 l 1� f ADDRESS /
CITY CL/g/ STATE ZIP TEL 77 r
Y
FAX CELL EMAIL
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