HomeMy WebLinkAboutBLDP-26-628 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY/TOWN w ' C M D t/ f �`- MA DATE 7 [' /l r, PERMIT
JOBSITE ADDRESS LA ? 5 LL./ -C-n L I C / -vt' OWNER'S NAME)----dL 4.e/—
OWNER ADDRESS ) 2 TEL U Z-/$/73 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:R. 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 Ric C E I \! E I) )
DEDICATED GREASE SYSTEM l
DEDICATED GRAY WATER SYSTEM JUL 28 ?026 's
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN fl`'
FOOD DISPOSER jr I
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES /
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 0 NO❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY fXl OTHER TYPE OF INDEMNITY El 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 h General/j Laws. q/ 2. ` v�
PLUMBER'S NAME�I I GGti L /1(ijr7ILA LICENSE# 19/ /M P e. t,L SIGNATURE
MP ElJP E1 CORPORATION❑# t PARTNERSHIP❑# r 0 0. LLC❑�#
COMPANY NA -`ME 1 C8 C I Lo l J T l+ ADDRESS 3 7 �� (�G k ✓t 1 V't 4 "p
CITY /friM �/l n/� I S. STAT ZIP 0 // 0 / TEL 77 (7 7/ O `j/
FAX ` CELL EMAIL 5h/v3- / Mc 1,crin (Q?kit I L'(04\"\
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