HomeMy WebLinkAboutBLDP-19-006151 •
MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
/ CITY A'�h1�A MA DATE /}/�R4G ,1 :0/4 PERMIT#�J4/'/77�G' 4!'7
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JOBSITE ADDRESS 16 3 2LE ZPr OWNERS NAME -I-4
OWNER ADDRESS TEL So$- 77 i 3 44 6 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL[✓]/' EDUCATIONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMI I I ED: YES❑ NO❑
FIXTURES 7. FLOOR-I 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
LAVATORY
ROOF DRAIN
SHOWER STALL •
SERVICE I MOP SINK
TOILET s
URINAL eR74/fiV ;•
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES4-
WATER PIPING
OTHER �fl
STc.ww• 344
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Er NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 17 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
it 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 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.
PLUMBERS NAME Lt1rL�,o,.,-, A11-0,11 /'„ LICENSE# /L02/ , SIGNATURE
MP ✓[ JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC D#
COMPANY NAME /f I4" J-e.t,,"-c ADDRESS Yr- /176si,✓ S7-•c.4.4
CITY Gun) �(. STATE Mh ZIP al- SL 3 TEL S 09 776 /a 0 S—
FAX CELL -77V Ye 7 5./70 EMAIL 1,//s .730 ,7-7-4-i/l (cam,,,
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