HomeMy WebLinkAboutBLDP-18-002308 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY ( \16(7l/1 OA MA DATE P RMIT# //VF"47036-6f.
JOBSITE ADDRESS �� FQ(Ze 4- ( ` t OWNERS NAME I +t7,2 T 6—o E
OWNER ADDRESS sPI TEL SD4La� I&AX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[/
PRINT
CLEARLY NEW: ❑ RENOVATION: V REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR—+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 1./
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 C
``� 14')7
LAVATORY f •
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION , /
WATER HEATER ALL TYPES V
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 NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE YPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND ❑
OWNER'S IN URANC R:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
1` Massachusetts Ge L , and that my signature on this permit application waives this requirement.
, _ CHECK ONE ONLY: OWNER AGENT ❑
IGNAT F OWNER OR AGENT
``=1 I hereby certify that all of det ils and information I have submitted or entered regarding this application are true and accu to the best y knowledge
and that all plumbing work stallations performed under the permit issued for this application will be in corn nce Pe provision of the
Massachusetts State Plumbing Code and Chapter 142 ofthe General Laws. '
PLUMBER'S NAME LICENSE#// 1,9
MP[r JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑Li#
COMPANY NAME��bi '�VI i3 "� ADDRESS po Rc.) b7 3
CITY (� STATE? ZIP (;)2 S / TEL )d / "/
FAX CELL gS7 /4'Z/ EMAIL
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