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HomeMy WebLinkAboutBLDP-25-959 MASSACHUSETTS UNIFORM APPLICATIO FOR5PERAAIT O/JPERFORM PLUMBINGWORK MI n -L_..9. CITY //�J {�J MA DATE i Z.! 1 S PERM! # AZ/':ZS � 1\\ JOBSITE ADDRESS L(/ / 7 /` 28 OW ER'S NAME / I e L- POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL❑ RESIDENTIAL 0 PRINT PLANS SUBMITTED:YES❑ NO❑ CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:❑ FIXTURES 1 FLOOR-. NM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND 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 I MOP SINK � _ TOILET DEC 1 1 CU4J URINAL WASHING MACHINE CONNECTION f ( w WATER HEATER ALL TYPES �__ WATER PIPI G nc OTHER r 6fit c.-F.fn) GGGG INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES tr NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYP COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABILITY 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 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 compli ce with all Pertinent provlsion of the Massachusetts State Plumbing Code and Chapter 142 of the General'/ Laws. ,p i� PLUMBER' inMAIOTO ) V/ ICENSE# /� i6 SIGNATURE MP JP .t q'Imo/ CORPORATIONIO 0# PARTNERSHIP 0# LLC 0# �� COMPANY NA ME 1-06 I/`—i r,J����dADDRESSS� 4 (r i MC 2CITY STATE AM ZIP CJ� 73 TEL f E/5t'c`J961S FAX CELL EMAILe )4 M 4�16lb1J`x q1/412it I 1 , , ......„ 3 . 4,• ,,..., i 4,,,,,.,„,,i4__, ,,r- .,.,,,,,x,,. ,,,,, d c.(4.t}tilc. tit 't-.4'.'- .'-',4, , .4 11,A2p.'4,'•-'44:4 '711'1k 44,4.4.1/4,...:,&‘i41.47A-;''...-11 r°. 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