HomeMy WebLinkAboutBLDP-19-006841 '4
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
-/ CITY S Cyti Ti d \(Att.Ackrok MA DATE / 3(k' PERMIT# /PAg /r-ia 01 '%/
JOBSITE ADDRESS C.O. V"C1d'1s.1 OWNERS NAME Obe 1>1: Ph((
OWNER ADDRESS TEL V-1A8-aelti FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Er
PRINT
CLEARLY NEW:,( RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMI I I ED: YES ❑ NO
FIXTURES- FLOOR- BSM 1 2 3 4 5 6 7 8 9 16 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 i
LAVATORY
ROOF DRAIN -R +ECEIV Q _
SHOWER STALL •
SERVICE!MOP SINK
TOILET a MN O ? 2Q1g
I URINAL
• WASHING MACHINE CONNECTION (, _
WATER HEATER ALL TYPES '
' WATER PIPING _ _
OTHER
INSURANCE COVERAGE: 1
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES E NO ❑
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.
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 my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _ n
PLUMBER'S NAME rM\GAtt-EL A•1 LICENSE# \5' A 2 NATURE
MP 1E JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME r-woDE PohAP,IkkG- i4 U4- ADDRESS ('3S C 90 SN,.K1J .d44.
CITY S. AttAtkrriA STATE MA- ZIP (32CC4 TEL fly 't`-‘- (BS Li
FAX CELL EMAIL CH ELI143FPl.VMtSI).6 €)`U kc)C. CcM
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