HomeMy WebLinkAboutBLDP-23-11868 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY ya//V1 ) '1 FL1 l0tt MA DATE / / /y- 2 3 PERMIT# DP- 23 - 11Q69
JOBSITE ADDRESS 3 OWNER'S NAME ? - l-Ic G(�,S ke./
� Mc��►hers lr� �
OWNER ADDRESS TEL 774 - ./9 3 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL j/
PRINT
CLEARLY NEW: RENOVATION: V REPLACEMENT: PLANS SUBMITTED: YES NO
FIXTURES-1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB I
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 1
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL .11:_ , iL3
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES y� _I J ;L. fai� :� ��r
WATER PIPING 9 �v
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES v NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Yr OTHER TYPE OF INDEMNITY BOND
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 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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME �U ,Rf��S yV, tj-/) LICENSE# (Yl�(�'0L{ SIGN AT
MP j/ JP CORPORATION .313/ PARTNERSHIP # LLC #
COMPANY NAME 6., Qp 1(trr pc64.kL ADDRESS CAA
CITY ti.), � Q (�Mu L' � STATE. ZIP 6.,'7 TEL (19 S'36-O -(.
FAX CELL EMAIL (`.A I') l cclvh