HomeMy WebLinkAboutBLDP-23-11604 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK
CITY (x Lf O/t(it MA DATE 5/3/Z3 PERMIT# .I)/ 3/IGD '
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JOBSITEADDRESS 21 Frank I n-, s" OWNER'S NAME UO�nq " 2CGG
OWNER ADDRESS 0-I it I ry% 54- TEL 50g.- 0,7-13 64AX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL(�
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES D NO Ell
FIXTURES 7 FLOOR-, aSM 1 2 3 4 5 6 7 a 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE _ _
DEDICATED SPECIAL WASTE SYSTEM _
DEDICATED GASIOIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM —�
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN R E L v. '']]]�']��__fL)
INTERCEPTOR(INTERIOR)
KITCHEN SINK �; 0 3-
LAVATORY
ROOF DRAIN vATM NT
SHOWER STALL tulrc 'P' -. —
SERVICE I 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'a NO 0
IF YOU CHECKED YES,PLEASE INDICATE
THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POUCY P] 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 that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
LI 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 all plumbing work and Installations performed under the permit Issued for this application will be In compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAM Mi21l11 GJII 'CG fc1#7 LICENSE#31156 g SIGNATURE
MP 0 JP CORPORATION 0# PARTNERSHIP❑.# LLC 0#
COMPANY NAME Noll COI'eniao ( 4 it ADDRESS Lc-COII Sf
CITY Lj ''Y larmo f,I1 STATE /[4 ZIP C�,C 7 3/ TEL�1
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DIVISION OF OCCUPATIONAL LICENSURE
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1, LICENSE NUMBER EXPIRATION DATE SERIAL NUMBER
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