HomeMy WebLinkAboutBLDP-23-11794 �6 fir
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
=4f-. CITY s � �1 MA DATE /0 26 -22 PERMIT#BZDP,— 17 23—19y
JOBSITE ADDRESS !D f✓GlldOd,� �/�OWNER'S NAME k,�,-[/
P OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED:YES 0 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 GASIOIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM _
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK ,
LAVATORY _
ROOF DRAIN RECEIV-ED
SHOWER STALL —
SERVICE/MOP SINK TOILET / [na
2 0 1U2
URINAL
WASHING MACHINE CONNECTION R.ni DIING DEPART viENT
WATER HEATER ALL TYPES e)
WATER PIPING
OTHER
5,-u/4-0 a- e.c v/L /
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0
IF YOU CHECKED YES,PLEASE INDICATE TN E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY tur
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 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and Information I have submitted or entered regarding this application ar and a t to best of my knowledge
and that all plumbing work and installations performed under the permit Issued for this application will be in 'Hance wit all e nt provision of the
Massachusetts State Plumbing Code and/Chapter 142 of the General Laws.
PLUMBER'S NAME A�'/V/S �/.C/�!///df LICENSE#//t62 SIGNATURE
MP IV JP❑ ! CORPORATION 0# PARTNERSHIP 0# LLC 0#
COMPANY NAME �)/'.e�NL�,`5�"A Cr01 4/4'S J / ADDRESS Ad, E4c /79 c5 C,
CITY AL E4 1 '77/ 4 �/ STATE ZIP O 2, 5 TEL 179 3✓3/ 7"V1
FAX CELL/'y3s vq7 EMAIL Q,cei,i c� 6,-/-/Uk
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