HomeMy WebLinkAboutBLDP-18-005157 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
UT CITY \PRI%ou ill MA DATE (33 f 1 ! / 4 PERMIT#/91-017-a-ate:)767
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JOBSITE ADDRESS S� G,LfJSJ vOOtTD ST OWNERS NAME G1VeLLy W J
POWNER ADDRESS 59 att..) aloof) 5.4 TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 2/-
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:Q' PLANS SUBMITTED: YES❑ NO'
FIXTURES 1 FLOOR-+ BSIv1 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 I
INTERCEPTOR(INTERIOR) 1
KITCHEN SINK
LAVATORY -
ROOF DRAIN I
SHOWER STALL I 1 _
SERVICE/MOP SINK _
TOILET
URINAL .s )
j WASHING MACHINE CONNECTION '''.-?(,,C-:_t,
WATER HEATER ALL TYPES .1 7 •'! '-f''` "
WATER PIPING /
OTHER _ 44)4;
6
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES( NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY II, OTHER TYPE OF INDEMNITY ❑ BOND 0
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
j1 Massachusetts General Laws,and that my signature on this permit application waives this requirement.
.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
lei I hereby certify that all of the details and information I have submitted or entered regarding this application are true and ac o the best of my know ge
and that all plumbing work and installations performed under the permit issued for this application will be in compli with all Pertinent r vision of
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME V 1'C6/L,,;' S'(,VA LICENSE#3439.s SIGNATURE
MP❑ JP[E' CORPORATION❑# PARTNERSHIP❑.# LLC❑# /k J/-
COMPANY NAME --Si LvA PLu,��ji;LCj�J ; G, ADDRESS IS-5—SUAbug y LA,,,-- 'J
CITY Hyk.v,,/ STATE.M4 ZIP O igQ1 TEL
FAX CELL7Ai i36 0J 7G EMAIL yi ea,ti 0_1064 tic4frvoiL - €40411
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