HomeMy WebLinkAboutBLDP-19-000201 .O7nt aAAva
r • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
h!IWJ CITYy/re/A-0 U f MA DATE 7/ /L/V 1 i PERMIT#r17Pif--6 (06f/
JOBSITE ADDRESS 1 in/rickL )2 2-7a%-.14. 3 OWNER'S NAME ACiM1 /
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POWNER ADDRESS If ,i? l�C.%4/�j'� ✓/-7-ivA"L; /797i'1 �7 .� CY5r- AX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[ }-'
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CLEARLY NEW:[RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMI I I ED: YES NO❑
FIXTURES 7 FLOOR BSM 1 2 3 4 5 6 7 8 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 —
FDOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) -
KITCHEN SINK ,d _
LAVATORY / ) -
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
1 TOILET ` / t2 ,
I URINAL _
j WASHING MACHINE CONNECTION •
i WATER HEATER ALL TYPES
WATER PIPING /
OTHER j33, D.nk /
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO 0 I
IF YOU CHECKED YES, PLEASE INDICATE THETYP OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND ❑ &411
! OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
i` 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 true d 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 complia ce with all Pertin ' 'on of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. '
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PLUMBER'S AME ,
LICENSE# "yY1 P 16�t I L� � SIGNATURE
MP JP ❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME .,6 ) C -\1 o/;•r.8-1( ADDRESS LI J gc* E'er 5 2 t(i1 t/7'* ;1rj
CITY 11 1---ri r? STATE )11!T ZIP Cor�I S �" TEL l a"/'3 Y?'-"i 9 S
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