HomeMy WebLinkAboutBLDP-25-524 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
'Wis— CITY L�•P$� yG)f'MOO /1 MA DATEiU/ • Q • PERMIT# QLO IL. T 5-11--‘1
JOBSITE ADDRESS L/ Co L 6 ur w f A OWNER'S NAME 5C6P�' I�r. �O ( t
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OWNER ADDRESS �,mPi TEL�7/ ���'�e��l RAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
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CLEARLY NEW:E RENOVATIO) REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NON]
FIXTURES 1 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/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) fi W
KITCHEN SINK / 1 f E I �'
LAVATORY / p�
ROOF DRAIN �5 � "
SHOWER STALL I AIL.-.8 '-"`
SERVICE/MOP SINK r
TOILET g� �Btt�FC [-IF ART`✓ 1 j
URINAL ---
WASHING ..
MACHINE CONNECTION B'
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,® NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY" OTHER TYPE OF INDEMNITY ❑ BOND E
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 0 LY: OWNER ❑ AGENT E
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are tru: -nd accur- - .the .est of my knowledge
and that all plumbing work and installations performed under the permit issued for this application wit be in co .•lance, " - •erti. t provision of the
Massachusetts State Plumbing Code and Chapter 14 of the General Laws.
PLUMBER'S NAME /69( rQ (JrOI LICENSE#3 "/ l SIGNATURE
MP❑ JP l CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME (I// i% l l ADDRESS / i 7GI/�I'E
CITY STATE 5 - TEL7(—) cc( .,� ad �� � y3
FAX CELL .. .116Q., EMAIL