HomeMy WebLinkAboutBLDP-24-826 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY/TOWN W l DU MA DATE 9 a5—ail �PP{ERMI�T# BIDP— Z� ply
CAI)JOBSITE ADDRESS `�d <f OWNER'S NAME / vtkL2r gtZ�l�f�
OWNER ADDRESS 3 L Cole S+ TEL, -.534-S5vo FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL[r
PRINT —/ /
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:lam" PLANS SUBMITTED:YES❑ NO L�
FIXTURES 0 FLOOR—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE I
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
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES(2' NO❑
IF YOU CHECKED YES,PLEASE INDICATE
THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY/2 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 1 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_an�Chapter 142 of the General Laws. p!/�} //B
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PLUMBER'S NAME jrPk [mil LICENSE#33/33'J Ic�BJIB/. °SSIIGNATURE
MP[ JP CZ( CORPORATION❑# PARTNERSHIP D# LC❑#
COMPANY NAME l M'N' WI
-1 (6/ Uv1LCJ ADDRESS 17Kkf 1I
CITY STATE tiltk ZIP 033 ion TEL `(44 3
FAX CELL EMAIL k)zitimt el is t►�af,CO`I
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