HomeMy WebLinkAboutBLDP-25-359 .aL P- Zs- 359
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUME II4 & E 'V E D
-_11= CITY YA1��tuvTL/ i MA DATE -�s 26 2-5- PERMIT# • APR._25 2025
JOBSITE ADDRESS 9.3 / gi A D --1
-1 OWNER'S NAME
BUILDING DEPARTMENT
OWNER ADDRESS TEL FAX BY.
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:E 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
LAVATORY /
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING /
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Id NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY []v/ 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 I have submitted or entered regarding this application are true and accurate to the best of nowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance • II Pertirte ovisi f the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME yA(-6 ,V4- of LICENSE# SIGNATURE
MP❑ JP lid CORPORATION� ❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME
t/ ay/1120S f' 4 (1j ,e ADDRESS 24 ',v2'ivG
CITY WE5r 1/ ✓"tdUu STATE A44 ZIP CZ73 TEL 7714-cY ZS3c(
FAX CELL EMAIL W4Y^I f iKc Pe-,'m6E 6) r,4%L, ctiwl