HomeMy WebLinkAboutBLDP-18-003694 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY 7A Gi;i 3—I MA DATE /7 (Z.?__ \ I1 PERMIT#, / l8'®�✓09q
JOBSITEADDRESS 8o Cif-FINOQZE-J e---T-""F-- OWNER'S NAMETh—oSEP1 •�AN6LLI.
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL,❑j EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR BSM 1 2 3 4 5 6 7 B 9 1D 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 / •
t ROOF DRAIN
SHOWER STALL / / • _ 1F
SERVICE 1 MOP SINK
TOILET Z Z l/ �
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 U' NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [ 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
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
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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 tr and c the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co an • ertinent provision of the
Massachusetts Stat lumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME E-tz.e.C.-. LE.C.L`€ C- LICENSE#2.(00 -Z SIGNATURE
MP ❑ JP CORPORATION 0# PARTNERSHIP❑.# LLC 0#
COMPANY NAME ( L.v M ;N 6 JJ E ATADDRESS P
� I o . }3a x 1 ,983
CITY `f- Q.4.Es STATE MA ZIP O y44 TEL SOE-`9Z-7Z49
FAX CELL EMAIL LEC_LELCbE_ZEKSC e Act—. Cc,^7
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