HomeMy WebLinkAboutBLDP-17-001157 off /°
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY S ./0147 c,c-=" 7 MA DATE f v PERMIT# it G
JOBSITE AD ESS /I �i71 - 1 OWNER'S NAME
OWNER ADDRESS � i4 <el TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT /
CLEARLY NEW:❑ RENOVATION: L1' REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7 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
URINAL
WASHING MACHINE CONNECTION 1
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. YES'NO ❑
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
1
LIABILITY INSURANCE POLICY 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
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 •- if my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in corn fiance with all ": i •nt pr. ision of the
Massachusetts State Plumbing Code! Chapter 142 of the General Laws.
.40
w PLUMBER'S NAME 64/6y 1 fr"�' LICENSE#/off .1/ SIGNATURE
MP JP❑( CORPORATION ❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAME /l� id ) L'ij' 9 ADDRESS €'L' (9L 1-11 1s kek
CITY ( � STATifr . ZIP U� TEC DS L/(b
FAX CELL 737 7c-)</c). EMAIL
•
9j
r �
. y
JD
O
0
U
Q
o
z
z
o F- r
a
W o
Z
ULu _
F- W
fi cn r.r
O Q11-1
O o
a
w Q
69.
= W
F- Lt
H
z v
IP
E
z �
zt
a
o
a