HomeMy WebLinkAboutBLDP-19-004403 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
r "1°-- CITY 4 0 ° `^�--� MA DATE 1 / lc, PERMIT# �I"? C)7 Tci
JOBSITE ADDRESS , '1 SI,l/Llir 4 /L OWNER'S NAME /Cc v 0 ji t°-Cf-i.s v
P OWNER ADDRESS 57%3-v,..,. TEL aS . 13‘d,1— FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALD_.....-
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CLEARLY NEW:0 RENOVATION:Ea'- REPLACEMENT:0'` PLANS SUBMITTED: YES❑ NO 0
FIXTURES Z 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
LAVATORY
ROOF DRAIN _
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES i
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 VNO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 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 0 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 }}}aaaand ac to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in y � �
nce •, Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /
PLUMBER'S NAME LICENSE# `() S' SIGNATURE
MP,& JP 0 CORPORATION�# 301 Iv PARTNERSHIP❑# LLC 0#
COMPANY NAME 000 t., to cQ 144-e .4-.h t 6-1 ADDRESS ,6 Fr/164411 pc)'-
CITY c r ViAivii WIWI
STATE'"4A ZIP 0 A,(,,,6 TEL LSZ,'- 3c Y'"ZD/
FAX ,50 b -3j c y7 S_7 CELL 5-ct, 1r'J %5cii EMAIL Sr',�!.- ,#?(c'd i ecr c c (O
L<_1 . _.._ _ -_ . ; Gail.BUILDING DEPARTMENT
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