HomeMy WebLinkAboutBLDP-19-000619 MASSACHUSE I l S UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
- CITY /1t" bL1±+t MA DATE 7-g I - I PERMIT# Z P'/7—00G16
JOBSITE ADDRESS rj� 1 ID c\o\ -e.f.— OWNER'S NAME \' I►�] )T7 Q L
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: [Vf REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO❑
FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 B 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 a
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK _ _
TOILET
URINAL
. WASHING MACHINE CONNECTION
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 ❑
IF YDU CHECKED YES, PLEASE INDICATE TH TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND 0 D ev
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
11 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 t • - r.t: to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co pli. r• ■ •-• • • '_ • -
Massachusetts State Plumbing Code and Chapter
r1142�of the General Laws. {
PLUMBERS NAM (��r i �`�-`�a'` `` LICENSE# 326C1 SIGNATURE
MP Ed JP ❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑#
COMPA Y NAME3 ftvi -3'6e1s, ADDRESS f6)
CITY STATEYYNA-- ZIP TEL
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