HomeMy WebLinkAboutBLDP-25-882 MASSACHUSETTS UNIFORM APPLICATION FOR A ERMIT TO PERFORM PLUMBING WORK
11= CITY t/✓7C/ MA DATE J I •! PERMIT#C31�/mo �p ��
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JOBSITE ADDRESS w A�66741z`� e 7 O IR 0'�Jc�L,C/s.m
POWNER ADDRESS 1)"t TEL F
TYPE OR OCCUPANCY TYPE COMMER EDUCATONAL❑ RESIDENTIAL{—yj/
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/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM '
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER /J/— —,
DRINKING FOUNTAIN _
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY a,
ROOF DRAIN '
SHOSERVIECE I MOP SINK 1 NOV 18 LOLc
TOILET --
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER `7 /t4ilie f f -
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO 0
IF YOU CHECKED YES,PLEASE INDICATE
THE TPEOF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POUCY 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 acc ra a 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 Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# SIGNATURE
MP 0 JP 0 CORPORATION 0# PARTNERSHIP 0#t r LLC 0#
COMPANY EtI3)C_7 p-( ADDRESS L�/ill I f ON \( X-S�
�� STATE ZIP 626 ! 5 TEL 6C 2 ,34a
CITY �� av
FAX CELL EMAI 1
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