HomeMy WebLinkAboutBLDP-19-004988 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
__ = + CITY i;��i/ (/j1 / MA DATE ,-,/L 7/r
7 '- q PERMIT#.4 /'"J9 00 9/ -
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�> JOBS1TE ADDRESS ' C // , 77 OWNERS NAME
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES NO El
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
i LAVATORY /
ROOF DRAIN
SHOWER STALL .
i SERVICE/MOP SINK
TOILET 1
URINAL
. WASHING MACHINE CONNECTION ( ,' 1
WATER HEATER ALL TYPES 111
WATER PIPING /. 1
OTHER
.Jb.el /
INSURANCE COVERAGE: �/�
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES I NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY ❑ OTHER TYPE OF INDEMNITY 0 BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
t` Massachusetts General Laws,and that my signature on this permit application waives this requirement.
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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 rat to -e .est of my ge
and that all plumbing work and installations performed under the permit issued for this application will be in comp e with�0� •: t provisi
Massachusetts State Plumbi Code and Chapter 142 of the General Laws. -
PLUMBER'S NAME .oj�/ �/7/,'' LICENSE# /3 7°` SIGNATURE •
MP[11/ JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME eC ` ��.7. ADDRESS c z r /722.04:7" t 57
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CITY ,,��� "'' STATE �� ZIP ����y TEL crPe'e,oW e2g 7'!"
FAX CELL EMAIL 21.. �9 �e"d <.455!-/,- ,1
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