HomeMy WebLinkAboutBLDP-19-004531 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
—_eF= CITY yctt ' u )cL MA DATE 'D (a ` k ck PERMIT# /XJJP-JP- v y M
.�= JOBSITE ADDRESS 37a koAN? iv Pr ycJ Or OWNER'S NAME LDS 1; g
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO:n
FIXTURES 7 FLOOR—F 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 _ _
LAVATORY •
ROOF DRAIN
SHOWER STALL •
SERVICE!MOP SINK _
TOILET
URINAL
. WASHING MACHINE CONNECTION I.WATER HEATER ALL TYPES t ¢ ,:)_ i
WATER PIPING
OTHER
I I I
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 OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
rMassachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER [] AGENT ❑
SIGNATURE OF OWNER OR AGENT
Lk,-.1 I hereby certify that all of the details and information I 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 com ance with II P ine p vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ✓�
PLUMBER'S NAME LICENSE# 763L GNA URE
MP[ JP❑ 11 \ CORPORATION❑# PARTNERSHIP
1❑.# LLC
�t ❑#
COMPANY NAME cLG�1 3,OD1_ �� rt �� ADDRESS �a lvtw iNo%,-u� CZ.d-
CIT Y Vtt S J STATE 14 A- ZIP Ua L,3 E TEL 3 6`t=f 9 Y efe6
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