HomeMy WebLinkAboutBLDP-25-607 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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o CITY ` ff Wl MA DATE c3 I 1 q- I v25 PERMIT# 131-0P 2_6" ' (0o7
JOBSITE ADDRESS. / - U cf 9Rfrv164it ark OWNER'S NAME Andrea, S-40i+etis
OWNER ADDRESS (8 ln9 Qc-- &csu l 44 TEL• c2O O7F3 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:[V REPLACEMENT:E PLANS SUBMITTED: YES❑ NO❑
FIXTURES 1 FLOOR- BSNA 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
LAVATORY
ROOF DRAIN
SHOWER STALL _
SERVICE!MOP SINK
TOILET , K tk. E D
URINAL _._ .._. ..__...
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES 14 2025
WATER PIPING
OTHER .BUJI r;U:f Aj. NT
By
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES L NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY 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 t y signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurat 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 a ine rovision of the
Massachusetts State Plumbing Code and Chapter 142 9f the General Laws.�
PLUMBER'S NAME / 0 LICENSE# /66 GNATURE
MP& JP❑ CORPORATION❑# PARTNERSHIP❑# LLC I2/#
COMPANY NAME L -1-Qi pL„,..4 b`^'')`�f7%' i.-ADDRESS
CITY 3 e t' l },•`cw�/� STATE MO- ZIP O.26'9 TEL 2 ( l Z J z
FAX CELL /Z ('Z EMAIL r• eota_/9? r(�),,•,
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