HomeMy WebLinkAboutBLDP-25-990 `1 �0
MASSACHUSETTS UNIFORM APPLICATION FOR Ae ER1AIITTOPERFORM PLUMBING WORK
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CITY Yr)(144014 MA DATE 0 2,21 a PERMIT#
JOBSITE ADDRESS 7611MaSS bT 1 OWNER'S NAME
P OWNER ADDRESS ! 1% MC 5 a TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: REPLACEMENT:0 PLANS SUBMITTED:YES❑ NO
FIXTURES 7 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 GASIOIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM _
DEDICATED WATER RECYCLE SYSTEM _
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN _
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK
TOILET 'a
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER LL
INSURANCE COVERAGE: R E C t GD
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGr DEC.-142. YES NO 0
IF YOU CHECKED YES,PLEASE INDICATET�TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BBLO G 2r 2 Z� (
LIABILITY INSURANCE POLICY CJ OTHER TYPE OF INDEMNITY❑ BOND 0 B 3 N4
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OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage repined by-Chapter44744l.--
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER❑ 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 compliance with all Pertinent provision the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.PLUMBER'S NAME { "'A1" colotAam LICENSE#3U13Pg SIGNATURE
MP 0 JP CORPORATIONJ�❑# PARTNERSHIP 0# LLC❑#
COMPANY NAME'/r 'ti° CO ft eV A(141 I d l I MA ADDRESS
5r e011 LAC/e s-� p/r
CITY to 4 �L�A Pf.OW G✓t ( STATE ZIP 6eCi 775 (/ pTE�L/�93 8--8 5�''(9l
FAX CELLS' -8t -g(Z EMAIL�Iai Cote9,{ �l 79JS.Ca2 O/la.COIG'L