HomeMy WebLinkAboutBLDP-19-005711 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY 7 MA DATE �"�//V�� PERMIT# / �� a��/!�
,.,, JOBSITE ADDRESS / 3 (, '- - 6-e-t-A t Ic/''`OWNER'S NAME 1)14.-P (! .c..I(-
POWNER ADDRESS S ` - r'— TEL 31.-b7e'f4AX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL�]
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CLEARLY NEW:d RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO❑
vFIXTURES"1 FLOOR-4 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
iDEDICATED GREASE SYSTEM -'
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
\J DISHWASHER PRFCEIVED
DRINKING FOUNTAIN
FOOD DISPOSER _� e 1
FLOOR/AREA DRAIN Q`
INTERCEPTOR(INTERIOR) ___
KITCHEN SINK BUILT G DEPART4ERT
-0 i LAVATORY I • —
ROOF DRAIN _
N SHOWER STALL
SERVICE/MOP SINK
. TOILET [ {{
Si URINAL I I
OI i WASHING MACHINE CONNECTION l
WATER HEATER ALL TYPES
WATER PIPING I
OTHER
i 0 6:5 _ ...
1
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INSURANCE COVERAGE: ,�s
ei I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO l�
I
S I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
I/ LIABILITY INSURANCE POLICY ❑ OTHER TYPE OF INDEMNITY ❑ BOND ❑
i OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts neral L , a d that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER TS17 AGENT ❑
SIGNATURE OF OWNER OR AGENT
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 . ' . - • •.' .•• of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. n
PLUMBER'S NAME'd�"I A "'4`21'0 LICENSE# 1333"I. /CJ SIGNATURE
MP JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPANY NAMEepa r^-a-I ,a 4+ e w& 2 t o ADDRESS /S (4.)i it)Sa •1+-a R.12
CITc V A_ft')o u STATE &IA ZIP 0 L ` 1/ TEL 6 11) 4 3 3 r S
FAX CELL EMAILD 4✓'/'e-/ C4 fits 1/4-is b by n ..0\r tit. .
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