Loading...
HomeMy WebLinkAboutBLDP-17-003781 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK (Mr: CITY E YA Q f 0 U f J — I MA DATE mem= PERMIT# /Pr'/7`6 ) ' JOBSITE ADDRESS 5 0 (,0•d )fSr n Pd. OWNER'S NAME /fJcJ S-v (_1 I 1 POWNER ADDRESS _ _ - __ _ TEJ5o0 360-3O -i 1FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL El RESIDENTIAL Er PRINT CLEARLY NEW:© RENOVATION:© REPLACEMENT:0/ PLANS SUBMI I I La YES® NO© FIXTURES 7 FLOOR-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I it II �1 Imo' CROSS CONNECTION DEVICE urri 1 s _L__ I DEDICATED SPECIAL WASTE SYSTEM I I _ 1_ DEDICATED GAS/OIL/SAND SYSTEM ; '� .iNM , i�' gyp 11111111 INS DEDICATED GRAY WATER SYSTEM MI _ i _ Ii ', 11110E, IMIMMEIIMMIL DEDICATED WATER RECYCLE SYSTEM MI MN JORIMIWINWOMI __ MIIIIIIIIEMEMIRM111,1M DISHWASHER Mg_ I.,___ 11_11 1 1 _ _ _ n __ , FOOD DISPOSER : 111101111,MaingtMi_ .,,W,MMIE114111EI,11-1-11K ill FLOOR/AREA DRAIN ign , RR. _ _ ournirourmilimai 1 RR . INTERCEPTOR(INTERIOR) KITCHEN SINKi al; �I _ miiimig SHOWERIuiiIIIRIiiiIiR II WATER ' IIIII: - - -- -- - -- - ._. i _. 1, r,- - -- --- I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 21/NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Lb6 OTHER TYPE OF INDEMNITY [J BOND El 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. CHECK ONE ONLY: OWNER 0 AGENT 0 ' 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 a to to the b t of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in c:oa''n Perti provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME ki ,,.ri) oBrj P _ 'LICENSE# I _tao , ATURE MP Wf JP ID CORPORATION Yi#0246-C. PARTNERSHIP-_ # _ _. J LLC[1# _ -__ I COMPANY NAME c rNA, _ j ADDRESS __ _ • CITY __.W. Yp,.-n.,a y4A STATE MA ZIP Oat 7. TEL (6 O ?Ntra.-.4t4 1 FAX 604 79 o-ti-fu�CELL 1 EMAIL �' I . ,^ � AN 24 201 r - BY