HomeMy WebLinkAboutBLDP-19-000834 MASSACHUS I 1 S UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
L CITY (j Y41/.41/ MA DATE e�q/e PERMIT#4-4/9/ -791J'jf E39
JOBSITE ADDRESS O • elb,74.- l/nr OWNERS NAME 1g1", l �!/h?
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL�-
PRINT
CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMI I I ED: YES ❑ NO 0"-----
FiXTURES T FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICj rr) / 1 _ _
DEDICATED SPECIAL WASTE SYSTEM _ _
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER 1 •
DRINKING FOUNTAIN ''
FOOD DISPOSER tj1cv:- , 1
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) _
KITCHEN SINK 5 i 97400°
I LAVATORY •ROOF DRAIN
SHOWER STALL
i SERVICE/MOP SINK
I TOILET
URINAL _
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
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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 I�,� NO 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY i2" OTHER TYPE OF INDEMNITY ❑ BOND ❑
I OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
l` 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 of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. '
PLUMBER'S NAME k)((((ic.)vaGl� LICENSE#//18? n � 51GNA
MP [Ki" -JP ❑ e CORPORATION PARTNERSHIP❑.# LLC❑#
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COMPANY NAME - -2,.S 19/ (4 ADDRESS / eGx -zu
CITY Ai < L3J STATE r ' ZIP a72 r TEL�� ,3‘,, 3r5
FAX �V `J CELLce)g L740 7 3& (1 EMAIL 0 1.146)
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