HomeMy WebLinkAboutBLDP-25-238 MASSACHUSETTS UNIFORM APPLICATION FOR A PER IT TO PERFORM PLUMBING WORK
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-1_ • CITY MA DATE 5/I1 2S PERMIT#I1LDP-L -L3!
JOBSITE ADDRESS OWNER'S NAME
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL ay--
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES NO❑
FIXTURES 7 FLOOR-, 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 �fi
DISHWASHER .J� r .
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK _
LAVATORY _
ROOF
SERVICE •/MAP SINK I ' e � a�
TOILET -' - ) }, . �
URINAL L
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WASHING MACHINE CONNECTION 6 �FN�h [t.IT
WATER HEATER ALL TYPES /�� .1 ill SING [
WATER PIPING may"_ �"Y -4 ~
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 YOU CHECKED YES,PLEASE INDICATE THE TYPE OVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIAGILTTY INSURANCE POUCY❑ OTHER TYPE OF INDEMNITY 0 BOND 0
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
2
r CHECK ONE ONLY: OWNER 0 AGENT❑
SIGNATURE OF OWNER OR AGENT
L: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 compli rice with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBS ' AME LICENSE# , if SIGNATURE
MP JP '�j CORPORATION❑# PARTNERSHIP
0..#,, /�. LL�C n❑# �J
COMPANY NAME fj/ ^*J"1 '-� ( M F�ADDRESS L��/'i\ [ +O►V (L.,l)
CITY Yk�WO v 1-0� STATE MA-ZIP 0 TEL S'5 Q (�
FAX CELL {/'✓^ CJ cj