HomeMy WebLinkAboutBLDP-25-530 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
C DATE Z�
' PERMIT# lit 0 P-2 S-/ -3
JOBSI ADDRESS /7 ({ / OWNER'S NAME
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL 0
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED:YES 0 NO❑
FIXTURES 0 FLOOR—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM R E C F ! V E B
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM JUL 14 1025 1 -
DEDICATED WATER RECYCLE SYSTEM TI ii DISHWASHER DU WING!It AlH tFiMENTl'
DRINKING FOUNTAIN By. j
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK I
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❑ 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❑
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 I have submitted or entered regarding this application are true an ac u to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be i plia I ertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE#/s 7f 5 SIGNATURE
MP 0 JP-Zi/I�1 CORPORATION❑# PARTNERSHIP 0 itLLC❑#
J COMPANY NAME )G hh iS i 4 (i ADDRESS
CITY tyeiereawi STATE ZIP 02--C1J2 TEL cg631-S vq g
FAX CELL go43/0/1 EMAIL T/ /7 IKJ� ,o6r,;C-0"'