HomeMy WebLinkAboutBLDP-24-1026 /G d. De)
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBIN AORK
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JOB SITE ADDRESS, . _-j41 OWN 'S NAME____Abl _
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[ ^
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Ex_4-'7 PLANS SUBMITTED: YES 0 NO 0
FIXTURES 1 FLOOR-• BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB ''lj
CROSS CONNECTION DEVICE J
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 + I
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY ___
ROOF DRAIN I 1
SHOWER STALL r ,
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SERVICE/MOP SINK = 7
TOILET � C' �`/ f a
URINAL
WASHING MACHINE CONNECTION D C 1,&..1 2U24 OIL
WATER HEATER ALL TYPES
WATER PIPING 1...._..
OTHER
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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 01111 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
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT El
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 a 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 complian .th ail Pertinent provision of the
Massachusetts State PI mbing Code and Chapter 142 of the General Laws.
PLUMBER-NA , 0(/ -417-Gfb t� NA RE
MP JP a CORPORATION Eli PARTNERSHIP❑# LLC❑#
COMPANY N E] 4I7 / ADDRESS Z6 4 A777. /C) V tZ4b
CITY Y4 LAC b U L I1 STATE rt"(itZIP_O26 7 3 TEL, 0�-) 346037
FAX CELL^_�___ EMAIL yGIc '(e/