HomeMy WebLinkAboutBLDP-19-005762 • rip %LAG NI") for,
MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
-'��- CITY ,P�� MA DATE / �� / 6� PERMIT# �v [l�
JOBSITE ADDRESS / 1 c:f7 , /-2 -Lh/l( VVNER'S NAMEkiV 4 TO'1�e J
OWNER ADDRESS 1_56Z s FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUC A�Ipf E I VAR IAL
PRINT
CLEARLY NEW:❑ RENOVATION: [ REPLACEMENT: APR 0 9 2019PLANS 4•UBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR BKM1 1 2 3 4 5 ___5 . - 7 8------.5� 10 11 12 13 14
BATHTUB 13UILBiiv-G BEPAflT C T
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
ROOF DRAIN
SHOWER STALL •
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 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 accurate to the best my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance wi Pertin vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME LICENSE#//a' SIG
MP [11/ JP❑ CORPO TION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME4e-r-7/ 'r4S ADDRESS b Wok'
CITY STATEM ZIP (02. 6-.3I TEL,52 7sy- //?y
FAX CELLS-Or fS r EMAIL
� �
h
\� �J
V �� �
�'
`~1\�J`
V
���\�\ �`
V `\V�\�
��
��)
\\
�� �