HomeMy WebLinkAboutBLDP-25-916 MASSACHUSSET�T/S UNIFORM APPLICATION FOR A P MIT TO
PERFORM[� PLUMBINGM \ WORK
_.l is oc L�=1��C—�� MA DATEI G—J PERMIT# (l �S=9/�
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-„F JOBSITE ADDRESS S� (2.-7- 2 a OWN R'S NAME P-11kL=-..
P OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL LV EDUCATIONAL 0 RESIDENTIAL❑
PRINT PLANS SUBMITTED:YES 0 NO❑
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:❑
FIXTURES 1 FLOOR-, BSM 1 2 3 4 5 6 7 6 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM '
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER ,
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR) I
KITCHEN SINK
LAVATORY
ROOF DRAIN ,
SHOWER STALL
SERVICE I MOP SINK ' - -
TOILET t �
URINAL
WASHING MACHINE CONNECTION •
WATER HEATER ALL TYPES I)EC 0 1 2025
WATER PIPING
OTHER f5A-C14_� )A m 1
5 f
INSURANCE COVERAGE:
I have a current liability insurance policy or its substan' equivalent which meets the requirements of MGL Ch.142. YE NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABIUTY INSURANCE POLICY 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 are true an curate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complian II Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME/ LICENSE# f SIGNATURE
MP JP 5 CORPORATION❑# PARTNERSHIP✓✓✓ ❑# LLC❑#
COMPANY NAME
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CITY Y/' (Z pT1 STATE_M ZIP v /� TTE,L� '/
CELL EMAIL V f IQ P `� 03
FAX /6r/ G{a a!l
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