HomeMy WebLinkAboutBLDP-18-000659 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 1
j �CITY � �.�- tj G/' MA DATE 5-- t f- t' PERMIT# ` /�/ �r�-aa 66/
JOBSITE ADDRESS '2 2 I (e tfed$St y` (G i ' OWNER'S NAME S'&-7 G'ret,--) 4Oct)
POWNER ADDRESS L 1/ Ce-t icr ( ' t_ TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL E)_ ATIONAL RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION REPLACEMENT: PLANS SUBMITTED: YES NO
FIXTURES 1 FLOOR-0 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) 1'
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET I
URINAL t
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER ,
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INSURANCE COVERAGE:
I 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
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 accura 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 th Pertinent provision of the
Massachusetts State Plumbing Code and
//Chapter 142 of the General Laws -
PLUMBER'S NAME Clrtor, 1.tx �tEi LICENSE# lidos-7 SIGNATURE
MP JP V CORPORATION # PARTNERSHIP # LLC #
COMPANY NAME L.c..7,44 M t fi ADDRESS 17 G%' , ;e $ Z, 161
CITY SG �(,) ;C Lj STATE 4/2 9 ZIP 0 '2_56 TEL `)'i _ j,3 --6/,7 6
FAX CELL EMAIL C(1 Wyk f 1 a) f yr e) ya L,coJ Cam
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