HomeMy WebLinkAboutBLDP-18-002573 , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
� CITY �u TA VC)Rtrvl0 h MAf e/z 7 T DATE / ? PERMIT#. /.�P`//'- -00157 I
JOBSITE ADDRESS I $ (0LFr/'S ci 2 OWNER'S NAMEQ /e ;a 7 it 11 i
POWNER ADDRESS `--') ►"A` t TEL Cv 11 S 3-44 Ax y
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL El-------
PRINT
CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: IN_/--- PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7 FLOOR-f BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE tl
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 CO 64%
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 L'� NO ❑
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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
1 Massachusetts General Laws,and that my signature on this permit application waives this requirement.
F-- CHECK ONE ONLY: OWNER 11] AGENT ❑
SIGNATURE OF OWNER OR AGENT
-':I I hereby certify that all of the details and information I have submitted or entered regarding this application are true accurate to t • If of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in c nce w' ' 4 .rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME LICENSE#/ .?b6, SIGNATURE
MP❑ JP❑ CORPORATION❑# PARTNERSHIP❑,d' `
. � Lc❑#
S
COMPANY NAME ADDRESS /7 ,J'Y 7l
CITY 1A)0 S'T h n+%)' ''Von._( STATE IA t/1 ZIP v 2 40 7 2- TEL �0 3-a3 y-4-4 %`f
FAX CELL EMAIL I SiL,Y f ) ,44 4_ CUB
'%.
cri
Fy
O
czq
U A
z �
z �
S
a❑o En
w F
U w 3
I- W
fi cn
O ¢ aw
w
Cl)
ca
w d
O o 1-1
I—
G�
._1
u_
tF)-
tf.) LLI
F- LWi_
GTE
H
0
z
0
H
U
z
z
0
cy ✓ K/tkG-�Q-