HomeMy WebLinkAboutBLDP-17-001019 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
C_L CITY y?i^ 14110 o h c Z- MA DATE fS-' —IA PERMIT# f'�Y-J)" 7-0.O/7
JOBSITE ADDRESS yb BR r n a ale le OWNER'S NAME JOS(-)Ph �E l-�C e
OWNER ADDRESS 7 6 r vv a/6.. TEL?W-Y. 5/-Y AX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:[Q"- REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES Z FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 f 12 13 14
BATHTUB + t
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM cpa"
DISHWASHER
DRINKING FOUNTAIN i
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
WATER PIPING
OTHER
INSURANCE COVERAGE:
have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ OTHER TYPE OF INDEMNITY ❑ BOND El
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 rid th my signature on this permit application waives this requirement.
_ite't/P;) CHECK ONE ONLY: OWNER GENT ❑
SIG ATURE OF OWNER OR AGENT
I hereby c ify 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 c mpli ce wi all P 'enntt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME LICENSE# c)aG6C, SIGNATURE
MP❑ JP L CORPORATION❑# PARTNERSHIP❑`# Lc❑#
COMPANY NAME 4L e7p7 ADDRESS /d T 4•'/(),9.5 ,5 1L
CITY Lv 1/hDtiCti S✓TATE,ryj/4- ZIP d 0)'( �T TEL
FAX CEL(�/7l?77 -(7757 EMAIL Pkila.j/,/Vertj &�-r�• G'd,
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