HomeMy WebLinkAboutBLDP-25-526 QiULOiN 1 ROOM 6—►2
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY 7i� 4 MA DATE JV(y// ZS PERMIT#BLP-�"SZ
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JOBS., ADDRESS /Iy S�AX/DicA WAY OWNER'S NAME
P OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT' PLANS SUBMITTED:YES 0 NO❑
FIXTURES 7 FLOOR-. BSM 1 2 3 4 5 5 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 I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY /
ROOF DRAIN
SHOWER STALL R E C E V E D
SERVICE I MOP SINK TOILET
URINAL JUL 1 1,.2077
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING B..ILDINt,ut'HRTMCNT
-8,
OTHER
INSURANCE COVERAGE: �f
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO❑IL I U I
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ctL
UABILTY INSURANCE POUCY OTHER TYPE OF INDEMNITY❑ BOND❑
OWNER'S INSURANCE WAIVER:I am a are 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 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application are and -r.e to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in :ny,�I P �r ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE#/S-715 SIGNATURE
MP❑ JP Of
/COORPORATION❑,# PARTNERSHIP❑# LLC❑# ?
COMPANY NAME J,P/I hYI)5 �✓1 aL L� p f 1/ ADDRESS /gz Q��-C./0 V ii/P&/L U
CITY 7�WOW IL W STATE ZIP 07'5-.8 TEL
FAX CELL 9 Q"63/ ,qtl 9 EMAIL
75 ,E r�S.ao /0-O DB'