HomeMy WebLinkAboutBLDP-17-003950 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
Q i CITY 1,1a r vl C IA th MA DATE I I , ( I ( 1 PERMIT#/ P 17_C7(-1
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/ JOBSITE ADDRESS L (pun teed va,i1OWNER'S NAME_ 11 1 a 1-1.) , C r 0 I
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P OWNER ADDRESS ',,, C _ 1 TEL 5C93.3 u 2 Ut 13 FAX Y1 I _
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO
FIXTURES 1 FLOOR-, BSM 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 _ _ A _
DEDICATED GRAY WATER SYSTEM _ "`
DEDICATED WATER RECYCLE SYSTEM t
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DISHWASHER F •J �1
DRINKING FOUNTAIN
7.
FOOD DISPOSER 4'-' :7
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FLOOR/AREA DRAIN - S tl� Z �-j'1\�
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL (..1...)
SERVICE/MOP SINK
TOILET
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 NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 71 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
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 a,pcc_u�rate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complian '1Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME c T D} YenfirPf�Q /, 17 LICENSE# 2 ' SIGNATURE
MP ; JP CORPORATION # PARTNERSHIP # LLC # 1
COMPANY�NAMEPhliv'QJ-e P� , i ADDRESS Fb �d k '7tc,
CITY C� ��it/�CY�Y`2 E + STATE i1419 ,.) ZIP j Ca .. L' S _ TEL -3-rry _07/6 .
FAX I CELL / EMAIL ji - (_a,71,
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