HomeMy WebLinkAboutBLDP-25-542 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
9i9rif
CITY S, Y Mint MA DATE "/ � � PERMIT# 3 L 0 P - (1 2-
JOBSITE ADDRESS 17 PI4 2A RD OWNERS NAME QI^!o Sts4 r' I
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALO
PRINT
CLEARLY NEW:❑ RENOVATION: ' REPLACEMENT:❑ PLANS SUBMITTED: YES❑ 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 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 /
ROOF DRAIN
SHOWER STALL
SERVICE!MOP SINK '
TOILET 1
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 NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND El
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 at 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. er.
PLUMBER'S NAME LICENSE# (0 SIGNATURE
MP JP❑ CORPORATION # d0p PARTNERSHIP❑# LLC❑#
COMPANY NAME_ T. F • Al°4T ES c 0# I .2 '- c— ADDRESS 7/ 6 M7 r E4 -f 4-C 5 7- 3L
CITY e 7'io, // STATE A ZIP D / TEL er7 AP 70 53
FAX CELL(Pi 1 d .3 7v S.,a EMAIL T}•00104S^'I' •
AA, 182025C 8-Li _
BUILDING DEPARTMENT
By — —
•
•
, •
,
,
,
t 1 Y,