HomeMy WebLinkAboutBLDP-24-864 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY yp Rro MA DATE /04/0" - y PERMIT#ULD?- z' - le(0
JOBSITE ADDRESS l) 7 ten 10 Re /'L;
1 O/q�-p OWNERS NAME M01C'ell-v
OWNER ADDRESS l 17 I,n•e'1 o e'At 1`�Qoff TEICOt) I$t'Y?6 b+ FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[-
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: 5tt. PLANS SUBMITTED: YES ❑ NO❑
FIXTURES 7. 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 I —~
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
i ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
§
WASHING MACHINE CONNECTION —
WATER HEATER ALL TYPES
1 WATER PIPING I I I I
OTHER
TUIL l�1iEiv
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 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
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 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 a Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME GRE6"i'Y LICENSE#?6?tY . SI ATURE
MP ❑ JP j CORPORATION❑# PARTNERSHIP❑.# LLC❑# b 6ft
COMPANY NAME Grt r4--.0-1R utvkfi q Cu v r-EL ADDRESS k S PRI A
CITY w• YARYNleaf4N STATE PIA ZIP oa613 TELLSae I Y3'(
FAX CEI R) i�l3y EMAIL ceIFc �t{� �yA.ede. CO(M
U
F•
0
z
z
H
U
Z
z
20
z v�
o
U
W H
0
w w z
L14 co cc
O ¢ w
"u a
O >
wLu
cn -
0
U
J
a_
a.
co
u-I
co
w
k
0
z
z
0
•
U
Ct
z
z
ca
a
•
0