HomeMy WebLinkAboutBLDP-25-468 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY r MA DATE !'� PERMIT# jLDP25 62
JOBSITE ADDRESS /-77Z410/7&?' AR OWNER'S NAME �m6O nnef�-er s
POWNER ADDRESS / /20 l sar eon TEL 7 f`'o7.68'4Wes FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL ra/
PRINT PLANS SUBMITTED:YES❑ NO❑
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑
FIXTURES 1 FLOOR—, I BSM 11 2 3 4 5 6 7 6 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
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 En" NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY W OTHER TYPE OF INDEMNITY❑ BOND 0
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 th; signature on this permit application waives this requirement.
J// CHECK ONE ONLY: OWNER ElAGENT❑
SIGNATURE OFJ WNER OR AGENT
I hereby certify that all of the•-r-s and information I have submitted or entered regarding this application are true and accurate to the best of my knovdedge
and that all plumbing work an.installations performed under the permit issued for this application will be In compliance with al +neat provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �f
PLUMBER'S NAME/1/-CSQS LICENSE# /60 / IGNATURE�S
MP JP❑ 'Q I CORPO�RAATIOONN❑.�# PARTNERSHIP❑# LLC u# p
COMPANY NAME 00 dS'^^^--1,"''�.14 O ADDRESS 30( a-< — rs/ —'{ `�
CITY 11J€51 / I e ` 41 STATE/1/ ZIP 0� ,c��2,3 TEL 7z 0)S//Z g�
FAX CELL '�f/ /2 SZ EMAIL = �2CI
JUN 06 2025
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BUILDING DEBABJIyIg NT
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