HomeMy WebLinkAboutBLDP-25-366 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
_,-`�j= CITY A�1'10 till) MA DATT...,E 4' -a`-1- a6 PERMIT# L D P-2 s- 3`S-
. '-peg 1 ( c (�
JOBSIT ADDRESS 6 7 1 o'1CC cJ OWNER'S�NAME DIAy'� r R fl b
POWNER ADDRESS 55 So'jci S TELl&'i /W7 600 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL X
PRINT
CLEARLY NEW:E RENOVATION:❑ REPLACEMENT:X PLANS SUBMITTED: YES❑ NO❑
FIXTURES Z 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
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN _ _
INTERCEPTOR(INTERIOR)
KITCHEN SINK R E C E I V FLD
LAVATORY .
ROOF DRAIN _
SHOWER STALL . APR-2 9 2025
SERVICE/MOP SINK
TOILET
URINAL t3UlLUINU UEI-All I MEN I
WASHING MACHINE CONNECTION sy
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 0 NO tqo
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ❑ OTHER TYPE OF INDEMNITY 0 BOND ❑
OWNER' SURA E AIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massac s tts n al aws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY,: OWNER X AGENT E
N TURE 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 e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS 4dinteD,
NAME 1C7 DIMS S is n IA i 5 LICENSE# 1 lei$ . SI ATURE
MP VI, JP❑ CORPORATION 0# PARTNERSHIP 0# LLC❑#
COMPANY NAME1OMA3 I- )'4oLrtts ADDRESS Q M401 5o/4S 1 A t'�
l
CITY Aunil;PI STATE JY1 ZIP 0 al i 0 TEL1 1`/ 3 L O4 '
FAX CELL EMAIL 1O14IDL.Mi5 5i) 1 t LO V D •C o pi
(/(-)-"
CAL
MOS eS qA