HomeMy WebLinkAboutBLDP-19-000534 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY MA DATE 7/.2.. /.6 PERMIT# ? P- Te?t'.�1y
r•.✓'FM a u 1
JOBSITE ADDRESS a 9 Ai k h 4.` K + / 1r e', OWNER'S NAME ! j J i-C
OWNER ADDRESS fee A., 'C TEL 7 s 2 q L-C FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO 0
FIXTURES 7 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 If
0 -DEDiCATED GRAY, WATER SYSTEM '
LU I
DEDICATED WATER RECYCLE SYSTEM
> SHWASHER
N NRINKING FOUNTAIN
MOO DISPOSER
r.OQR!AREA DRAIN
INTERCEPTOR(INTERIOR)
Lu j --> KITCHEN SINK
,r _ LAVATORY
" "' ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET ~_
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES (t
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 CVNO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY 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 and acc to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in 1'"nee Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME 4 i C zJ) A. 0 LICENSE# 7 �15 SIGNATURE
MP,& JP❑ CORPORATION rfai 30i(v PARTNERSHIP❑# LLC❑#
COMPANY NAME 6140 z Lr9t/y $'t'e(:L.- r 1 G- ADDRESS ga F'rPe,a,i'P
CITY C ` STATE•/84A ZIP C› 6.7 6 V TEL 5--6
FAX ,5 -3 c Y2s 7 CELL yet, ,J 5CJ EMAIL )p 7 tfie ;C/:i(0(4
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