HomeMy WebLinkAboutBLDP-16-003206 ( c-w- 7365) °firgam" e 01— /67 y�) 410.00
s ASSACHUSETTS UNIFORM APPLICATI N FOR A PERMIT TO PERFORM PLUMBING WORK
''•"= ' CITY/TOWN S. YC\✓•viboFv, MA DATE III o11 I aO1rc PERMIT# /� r/ 9 6
JOBSITEADDRESS 39 AS Voir- '4Wj OWNER'S NAME E•6Q-Inn ir(2-
P OWNER ADDRESS 500m2 TEL 503'351 (lo`j a FAX N to
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL%
PRINT �/
CLEARLY NEW:Jay RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO❑
FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND 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 1
SERVICE I MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING i 1
OTHER rjewoc�x.. es&k r
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 TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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: 0 ER ❑ A NT ❑
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are tru: -•d a rate • the best of knowledge
and that all plumbing work and installations performed under the permit Issued for this application ill be In complian ith all •ertnent provi •n of the
Massachusetts State PlumbingluCode and Chapter 142 of the General Laws.J
PLUMBER'S NAME T€$ V A. \i 6-A-) LICENSE# (aagg _ SIGNATURE
MP.( JP 0 CORPORATION al n 3 e-% I C PARTNERSHIP El# LLC❑#
COMPANY NAME E• R Wrv,a10,- 1"I� . be ADDRESS '3 aecrd w CA Cott_
CITY Svh lovv-cavn STATE MA ZIP Oa-Le(,H TEL 5)2 3q`1 "777 g
FAX GUl'3S - s29 CELL "la EMAIL QCCCve1T3100-1chi@,2Y101/4,•• .0M
S/A0/e- a6 c cefi/4
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fi74/2 7ZICY h0 7/ 79
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