HomeMy WebLinkAboutBLDP-25-525 cVILb a 2. kovxM$ / '/8 2z-Zif - ‘-/Z
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
• -a. " CITY JARMd0 1 MA DATE fGt-C//1 15 PERMIT# OLD P 2-",- SZ�
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JOBSITEADDRESS pi Si'wit is--A gig OWNER'S NAME QGCity XeSd1' /! ikkei'I
P OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:M PLANS SUBMITTED:YES 0 NO 0
FIXTURES 1 FLOORS BSM 1 2 3 4 5 6 7 6 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)
KITCHEN SINK
LAVATORY ,2 a
ROOF DRAIN
SHOWER STALL R E C E ( V E D
SERVICE/MOP SINK
TOILET An,`
URINAL LILL 1
1 (Mf;r
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING BUILUirrG DEPARTMENT
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO❑ I V I 1
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW CI0"
UABIUTY INSURANCE POUCY OTHER TYPE OF INDEMNITY IDBOND 0
OWNER'S INSURANCE WAIVER:I am a re 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 i,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 inn 1 all rtinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE#/579,5 SIGNATURE
MP 0 ..IPA CORPORATIONS 1❑# PARTNERSHIP 0# LLC 0#
COMPANY NAME ✓i s1)..1" C
) ,I Eel Pori ADDRESS 1 s z &T 6,4 .574IyjLi4C) Oct
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CITY STATE ZIP OM-0 TEL SW 6 31 SV t' 1
FAX CELL Svg-‘3/J"7 /i,/q EMAIL
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