HomeMy WebLinkAboutBLDP-24-1044 INU,615
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT
TO PERFORM PLUMBING WORK
CITY
Z yhrm dtl MA DATE/.!!" &6 2 y PERMIT#BCDP-'`-` /,`" '
JOBSITE ADDRESS �a refo qcy J/,61f OWNER'S NAME OANR S rAi
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL
PRINT
CLEARLY NEW:[Z RENOVATION:17 REPLACEMENT:❑ PLANS SUBMITTED:YES ] NO❑
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)
KITCHEN SINK /
LAVATORY /
ROOF DRAIN
SHOWER STALL / /
SERVICE/MOP SINK
TOILET
URINAL `�
WASHING MACHINE CONNECTION /
WATER HEATER ALL TYPES {]EC, `z 7 2024
WATER PIPING ,
OTHER FNHLrnN�OEPARTMEN
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 21 NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY in OTHER TYPE OF INDEMNITY 0 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 a ((uue and accurate t the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in plian wi all y vent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# SIGNATURE
MP❑ JP / CORPORATI ❑# PARTNERSHIP❑ LLC
COMPANY NAME u/ LiA C�y 7 rill. �
c •ADDRESS �/1 Iq'� S
CITY Rh Jug 7-N STATE..- ZIP Cb33 S/ TEL7f/ 3 8.9 el3 /I
FAX CELL iJ 97 67/ EMAIL
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