HomeMy WebLinkAboutBLDP-17-005770 •
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‘')Ku- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY yc�r v�nn✓7-}''1 MA DATE I/a.O l/7 PERMIT# /�1�J, �/yl7—GO
s5 JOBSITE ADDRESS as . 1 ic.y Vt o we 4cJ OWNERS NAME Ca✓l f a
OWNER ADDRESS D95 he kt'.n Si., rc.f, w„07412EL.6 6-962-/6-25 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL El RESIDENTIAL,'
PRINT
. CLEARLY NEW:El RENOVATIONS REPLACEMENT: ❑ PLANS SUBMITTED: YES ElNO ElFIXTURES 7 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)
KITCHEN SINK •
LAVATORY I
ROOF DRAIN
SHOWER STALL l
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
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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 and accurate to the best of my knowledge
and that alt plumbing work and installations performed under the permit issued for this application will be in compile ith all Perti rovision f the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME G r l S' zc1 I I LICENSE# S'g y( SI ATURE
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MPZ, JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME C c r I F. R; ect e I I + San ADDRESS -7 7 5
CITY O S t e r v i l l e STATE M A ZIP O a Co 5 5 TEL 50-- HI �s- C Co 9
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FAX CELL EMAIL
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