HomeMy WebLinkAboutBLDP-17-005165 ( MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
• ��— ' CITY /1/1e/t/EVI)4 MA DATE / PERMIT#/ /DP-/7�6's�6
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JOBSITE ASS__________________
l OWNER'S NAME �r(G L /G4i ./
OWNER ADDRESS Y41i AL11 TEL F X
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Tie
PRINT
CLEARLY NEW:❑ RENOVATION:21 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 /
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK 1
LAVATORY _ _
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING 1
OTHER
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 TH TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [ OTHER TYPE OF INDEMNITY ❑ BOND 0
' OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
j Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
'�.4 I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to t - best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co nce with all Pe . nt•rovision of the
Massachusetts State Plumbing Code and�pter 2 of the General Laws. �/ r f/ ��
PLUMBER'S NAME l !d�//J(�/ LICENSE#1.A?P GC GNATURE
MP 21 JP❑ CORPORA ION❑# PARTNERSHIP .# LLC 7-2,
COMPANY NTE,a ADDRESS /� L - '1i %o47Z
CITYG 7 1 "
STATE✓�d_ ZIP /�J TL 5W/0110.,/
FAX CELL EMAIL AfeM.W2P
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