HomeMy WebLinkAboutBLDP-16-006324 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY c �G1,1'r C�1.L 1 MA DATE _C _ PERMIT# / 0/'/6 606 6.:2
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JOBSITE ADDRESS 12)3 ct/of:tatcro n l ' ` ER'S`NrAME r I„jrk J�I��G( �C h
POWNER ADDRESS �pi TEL 714 -it 1-1
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO"
FIXTURES 7. FLOOR SSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORYROO F DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET _.._..---._.__...--_'-----_- ----------- ------_�
URINAL _...__...__
WASHING MACHINE CONNECTION ( _
WATER HEATER ALL TYPES
WATER PIPING I•
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 VNO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Li 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 1 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 c pliance with all Pertinent provision$the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /) _r
PLUMBERS NAME CratL} �ishop, LICENSE# 15101 ' SIGNATURE
MP Elf JP❑ l,}�, CORPORATION CI# PARTNERSHIP CI* LLC El#
COMPANY NAME tQ�l t"t"�-►�i e na i ADDRESS L.,")-1 �Oi L*2 t
CITY Fjin6.1/ 31CO STATE} , ZIP Ora5(43 TEL 5 2) e)a5-8(0 S
FAX CELL EMAIL r 1aj�I�l�c h-e �ci ce r'nCL' Co�
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