HomeMy WebLinkAboutBLDP-19-006799 MASSACHUSETTSA UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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' MA DATE s-hkA 5 PERMIT#/i 3' -/9 477 '
JOBSITE ADDRESS Bc � � OWNER'S NAME c/0 u-CC%L`L‘-
POWNER ADDRESS TEL TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL&
PRINT
CLEARLY NEW:❑ RENOVATION ( REPLACEMENT:❑ PLANS SUBMI I I ED: YES❑ NO ICI
FIXTURES FLOOR-+ BSI 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 1
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 I. 3
ROOF DRAIN
SHOWER STALL 1-
SERVICE/MOP SINK
TOILET I
URINAL
WASHING MACHINE CONNECTION I
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YEN NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY ❑ OTHER TYPE OF INDEMNITY ❑ BOND 0
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 a-t - r . a/da,te to,'e best of my knox
and that all plumbing work and installations performed under the permit issued for this application will be in om'\Ir- •k ent provision of t
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. i�,�- 04. A ,
PLUMBER'S NAM E�� z � oi2C— C___3(1 .) LICENSE#1 T� NATUREv�
MF JP❑ CORPORATION❑# PARTNERSHIP►J.# LLC❑#
COMPANY NAME nosAA '( VLJeZ3 LN ADDRESS 3 471 `-cC"O?6--j�
R2-6-k3-- C'Ver_____
74 1CITY STATEV-"'� ZI l TEL 2 F
FAX CELL EMAI ' S'
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