HomeMy WebLinkAboutBLDP-25-604 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY }/ rill(,)6+'C MA DATE/41)0 • l 3 rr c 3 PERMIT# J p
JOBSITE ADDRESS a. .C7 S *I ck-fr,e r W Oryi, OWNER'S NAME V:iy 1 r w
OWNER ADDRESS "414/ TEL FAX
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TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOIZ
FIXTURES 1 FLOOR-4 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/OIL/SAND 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 MGLh f4 ry I
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW a
qLIABILITY INSURANCE POLICY', OTHER TYPE OF INDEMNITY ElBOND ❑ .3 LULfi ?)
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage require b 142 of tha
Massachusetts General Laws,and that my signature on this permit application waives this requirement. by
D/L-PAR-WENT
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 tru nd accurate t e bes f my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in co nce ' II inent vision of the
Massachusetts State Plumbing Code and Chapter 1 of the General Laws.
PLUMBER'S NAME L Orke 053) 0 LICENSE# 30 7I IGNATURE
MP❑ JP J CORPORATION❑# PARTNER IP❑# LLC❑#
COMPANY NAME i3s �/U12^. v�( j -(?4�jf/'G 6/S/ADDRESS Cry 70 -t/
CITY 7-)nff L ) � STATE MA ZIP .67 J TEL
FAX CELL S--0(--?7t'(3 73 EMAIL /c1ri1j U..SSi/c . A`'r?/!_nc91 / (r'}��