HomeMy WebLinkAboutBLDP-18-006739 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITYk Vnye_Axi MA DATE PERMIT# 3P 27-MCP
JOB SITE ADDRESS / /, 2-14 OWNERS NAME G44.f zr /9N(
P OWNER ADDRESS �--- TEL FAX
FAX -----
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 2J/
PRINT /
CLEARLY NEW: El RENOVATION: ❑ REPLACEMENT: li/ PLANS SUBMITTED: YES ❑ NO Q/
FIXTURES- 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
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER •
DRINKING FOUNTAIN _
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK _
I LAVATORY -
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET T
URINAL
. WASHING MACHINE CONNECTION
I WATER HEATER ALL TYPES // _
WATER PIPING f
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of q c 1c7. Iffillie n
VI 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BE[O
LIABILITY INSURANCE POLICY 11.-'7' OTHER TYPE OF INDEMNITY ❑ BOND ] I MAY 29 2018
i OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required b}ti �A,AF:
Massachusetts General Laws, and that my signature on this permit application waives this requirement. w3 /
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
L'_I 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 II P rtinent prov. ion of the
Massachusetts State Plumbing Code and Cha r 142 of the General Laws. /f 'a �"
PLUMBERS NAMEfj( (( a LCE SIGNATURE
MP JP❑ /1 _S CORPORATION # PARTN SHIP❑# LLC❑#
COMPANY NAME /4: 0 ,DS ?(&/"C‘.
ADDRESS o Lb L" Za,
CITY- , J3 /v STATE 4" ZIP TEL
FAX 2 DCOY3 CELL 3�7 ,3-5‘ EMAIL 1 C 10? /Jd
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