HomeMy WebLinkAboutBLDP-23-11683 6g0o-°
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
_'.1" CITY/TOWN 'MIDUjN �T MA DATE S'/3i/23 PERMIT#{S LOP-IlLg3
JOBSITE ADDRESS 10 F.EL-M.A'I Rb, • OWNERSNAME 1 E13 ✓CX -r
P OWNER ADDRESS 77Me': rr
TEL yCV-(S 607). FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIALZ
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED:YES❑ NOgj
FIXTURES 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 1 _ ,
SERVICE/MOP SINK _
TOILET I
URINAL
WASHING MACHINE CONNECTION — g G E I V E p
WATER HEATER ALL TYPES —---
WATER PIPING
OTHER AN 3 1 2011
_ _ gj!LOINS DEFARTNFNT
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 gl OTHER TYPE OF INDEMNITY 0 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 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 applicatio nd acc to to the best of my knowledge
and that all plumbing work and installations performed under the permit Issued for this application will b in co 'nce a Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME !X`1 i go Ssc Ti LICENSE#/.0,1 E
MP, JP❑ CORPORATIONS# PARTNERSHIP❑# LLC 0#
COMPANY NAME rirb CA PL4.1P1AS-J6 ADDRESS jO• BWC I359
CITY K h VWSS STATE/ A ZIP 01660 TEL Sob'-9s''-5 .7o
FAX CELL EMAIL n1OrlRL:1Qp,WRC`"GM, l-. Ca-i