HomeMy WebLinkAboutBLDP-20-000497 r ;
•
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
_,—f CITY tlA.V- " MA DATE c.\ + .23 /5 PERMIT#i ct' a-cop
JOB SITE ADDRESS `l 6 , 2_ A WC 4 oip__ OWNER'S NAME 3040 dt'tw(J
,P OWNER ADDRESS S Q_ TEL FAX J
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL E RESIDENTIAL-
PRINT
CLEARLY NEW:E RENOVATION:❑ REPLACEMENT:, PLANS SUBMITTED: YES❑ NO❑
FIXTURES-1 FLOOR-4 BSIv1 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB _
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM •
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER _
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK _
I LAVATORY -
ROOF DRAIN _
SHOWER STALL ��
i SERVICE/MOP SINK i (_
TOILET '
URINAL /
WASHING MACHINE CONNECTION -
WATER HEATER ALL TYPES t
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 0
V 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
J_
UABIUTY INSURANCE POLICY E- 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
' 11 Massachusetts General Laws, and that my signature on this permit application waives this requirement.CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
LU I hereby certify that all of the details and information I have submitted or entered regarding this application are true and ac rate to e best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in com nce i all e nent pr ' on of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE#v /7 O'7 SIGNATURE
MP❑ JP CORPORATION❑# PARTNERSHIP❑.# c1 LLC❑#
COMPANY NAME �`\ —k)-t ADDRESS 9 f( 404'� `7
CITY Li ± 6#4 t 4-4/t, ,� STATE ZIP 0 2 6 TEL So 3, 7 2&—I Sod
FAX CELL EMAILq