HomeMy WebLinkAboutBLDP-23-11904 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY YL1/4( ff2 \- MA DATE tt Y �(: 3 PERMIT# ill-LW. 23 -►sci c-7
JOBSITE ADDRESS N1 1 r1 (9PS' OWNER'S NAME Skt'iNa vti ✓13
OWNER ADDRESS - R, ec-r-j/- TEL 1A Ytki-7715 FAX q,?i 301.1,1a�
TYPE OR OCCUPANCY TYPE COMMERCIALS EDUCATIONAL E RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES,[ " NO❑
FIXTURES 1 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
DRINKING FOUNTAIN
FOOD DISPOSER R E C E I v
FLOOR/AREA DRAIN l
INTERCEPTOR(INTERIOR)
KITCHEN SINK 1 e NOV 2 8 2023 1\
LAVATORY
ROOF DRAIN BUILDING DEPAKI viENT
L.
SHOWER STALL By
SERVICE/MOP SINK
TOILET .
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER 6cr a,..kL,
r—s
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES(O ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 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; . OWNE 2 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 curate the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co lance 'h all ertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE#
MP(JP❑ CORPORATION( PARTNERSHIP❑# Lc❑#
COMPANY NAME -,Clti' Pi,,,.10.,:1, r.-0 ADDRESS (Ze ctov' Ltrr-L1
CITYSO.) Y STATE 1`4" ZIP c ark1 TEL 'ir8- 344-770S
FAX 5.n"TL1' "CIL
CELL EMAIL k,v ar=,�. L��( (v C�--t,�„rJ�,:'. (`�M
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