HomeMy WebLinkAboutBLDP-19-006485 r:'' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
_' a. CITY i o N1. fk ( 441 MA DATE, 5//O//y PERMIT# /d'"/? O
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JOBSITE ADDRESS 4h �,` i OWNER'S NAME 1
POWNER ADDRESS 1 g �QCb; P \mac litCm , TEO od—98'.3`7gs q FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL 0 RESIDENTIAL g.
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CLEARLY NEW:(El RENOVATION: REPLACEMENT:0 PLANS SUBMITTED: YES❑ NOQ
FIXTURES Z FLOOR— BSM 1 2 ' 3 I 4 5 6 7 8 9 10 11 12 13 14
BATHTUB --M=N111 �1MCROSS CONNECTION DEVICE �. _ _-_ , _-_ RES
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DEDICATED SPECIAL WASTE SYSTEM
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DEDICATED GAS/OIL/SAND SYSTEM _ ( -
DEDICATED GREASE SYSTEM 11111111.1111111111Mmilmimalom
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM r MM
DISHWASHER _
DRINKING FOUNTAIN
FOOD DISPOSER
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FLOOR/AREA DRAIN
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INTERCEPTOR(INTERIOR) I MIN_
KITCHEN SINK 11111•1111 _
LAVATORY 1m '---
ROOF DRAIN T I—. `II�Iw 'NEI
SHOWER STALL MMI1M-MMWIMIII111111111111111111111111111111
SERVICE/MOP SINK rmall1111111111151111111.1111111111[11111
TOILET ''—'
URINAL
WASHING MACHINE CONNECTION T =R ai.. 0
WATER HEATER ALL TYPES ME MIN NMI MIN wilimom EN IMO IIIII '.IIIII INN MN 11111
WATER PIPING
OTHER 34 c- S,q,.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES t< NO 0
;F YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY RI 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 best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. S.
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PLUMBER'S NAME, 4 MPS , .� !LICENSE#116 $Q SIGNATURE
MPS- JPI] CORPORATION a,=' C• PARTNERSHIP'# LLC-1#
COMPANY NAMED Crn t Q, /-6. , ADDRESS .C, l eic, s R _ _
CITY ///-ors-t\kkkiLy-ViNs_ STATE 144 a ZIP 0 060 TEL 91. -.S l6` 6 goiO
FAX 5 I7- q CELL EMAIL So LI.yl1 f9,--(.7`,/v l(il Oa 4 Grvr-
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