Loading...
bldp-20-000065 • V . s_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK e( =_ter /� _) �4 CITY VCR(1McLrt{n p C,^, r MA DATE 7-,3- I q PERMIT#gQ/' a4-off 7 rr� Alofte sel� rts, JOBSITE ADDRESS 1 O& T,reC board L OWNER'S NAME C,Ndy %-tQ1,, 3ti,Fc tc POWNER ADDRESS S&v '- - TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL 0 RESIDENTIAL,© PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:N/ 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 1- DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM _ DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER ' DRINKING FOUNTAIN v:n FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) \4. KITCHEN SINK I LAVATORY ((f ROOF DRAIN i^ I 4 SHOWER STALL e _ _ „ . • SERVICE/MOP SINK i TOILET IL1 3 211 URINAL . i WASHING MACHINE CONNECTION WATER HEATER ALL TYPES - _ WATER PIPING _. '- " OTHER INSURANCE COVERAGE: I I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[f�' NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABILITY INSURANCE POUCY 0 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 ❑ 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 comp' n 'th Pertinen ovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. G�� �J� —^ PLUMBER'S NAME LICENSE#/5 4//� ��� SIGNATURE MP [r JP❑ CORPORATION 0# PARTNERSHIP❑.# LLC❑# COMPANY NAME SCArlakwj CIl (r4S ADDRESS -10 Crrceo Vt. 1 ke DIN vc_ CITY I'o re STcceI STATE )14 c( ZIP O a b`{-I TEL S08 3 47-itP77 FAX CELL So$ 347- L(O77 EMAIL Try 0\3 (D tort S iO, CO • GPei f