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Home My WebLink AboutP-18-5759 • (6n • �no 7d7 MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFOR1V P M 0 WORK - : s_L r CITiI rrAc r r ( MA GATE) t/Ii 31ix (PERdNTxQtv e'rt °urn` JOBS[TEADDRESs) (!0 (arn'(75/1.4,-, OWNER'S NAME) l�i Pcnn "-SOi_i . P OWNERADORESS I �•t Y1'1 P ( Ta)5t,i f- J?O9og4FAX I - TYPE OR OCCUPANCYTYPE COi MERCIALE] EDUCATIONAL 9 ' RESIDENTfAL-Z PRINT . CLEARLY NEVt9 - RENOVATTONZLREPLACEMBIT:© - :Plants SUBMfiIED YES El NOI( FIXTURES I. FLOOR-. - BSM 1 1 2 1 3 4 5 I. 6 i 'T 8 9 19 11 12 113 14 BATHTUB i (. • • _ i _ i. i _ -E. _ . 4 CROSS CONNECTION DEVICE .-!��aj ��{�T��_� DEDICATED SPECIAtWASTESYSTEM I I DEDICATED GASIOIUSANDSYSTEM ' ' +j DEDICATED GREASE SYSTEM L( 1 DEDICATED GRAY WATER SYSTEM ! - '- _ t A .' 1 � d DEDICATED WATERP.ECYCLESYSTEM ___1N ;. 1N r -�_j�, . y - C - ; _ DISHWASHER - , H 'Ij,{ Il_t__:..1__ :..1 _ J_ j 9 ..•7A ji IL t. DRINKING FOUNTAIN FFOOD DISPOSER S DRAIN - _ ' �O ��n a INTERCEPTOR INTER[•• KITCHEN SINK e ti♦�_nal 111.11011Mi•��ii�._.i�' LAVATORY n. '�"• I I 4 1 ROOF DRAIN r_ _ " A I ! I t SHOWER STALL iii. S _ _tr " ` SERVICEI MOP SINK �j�' ;�H J • " TOILET ' URINALr t , MIESIS WASHING MACHINE CONNECTION . - r -,7 • d 0 � WATER HEATER } 7 • T q r . . — WATER PIPING ii y __Si d - PIPING1_4I�.�,_.:_t_._„r OTHER ..a . .__� 1..a . al.lt''1_ i - r s -.-_ A a9-- a - _” "i a1 INSURANCE COVERAGE >L 14 IhaveacurlentfrablitvhuwancepoliicybrtResubstantialequivalentwhichmeetstherequiamentsofMGLCh-1I, _- r% N'IT— IF IF YOU CHECILEDYES,PLEASEINDICATETHETYPEOFCOVERAGEBYCIEplNGTHEAPPROPRIATEBOXBELOW Q� pa= QTHERTYPEOFINDEMNIT •Y U+ BI0 BONQ D � � �t i BUILDING DEPARTML NT OWNER'S INSURANCEIIVAIVElt I am aware that the licensee does not have the Insurante coverage required by M n•,ter lig oftgg----_ - Massachusetts General Laws,and that mysignahtre on this penmtappliication waives this requirement • CHECK ONE ONLY: OWNER Q AGENT Q SIGNATURE OF OWNER OR AGENT • - Iherebycertifythatalathedetaasandintonna5mIhavesubmittedoreNmadtegerdmpitisapptiofmarei sandamaatebthabestotorybnwleddge and that all plrnoblngwalk and indafatarspertained under the pant issued for this appllarwnroll be in can with all Pethneztpmvislan of The MassachuseBs Slava Plumbing Coda and Chapter142 of the General Laws. / • .�cO�r� moi•. PWMBER'S NAME+ 1.441/911 6ii¢I /EGO Zib TR ILICENSE W 9z `y 4 • SIGNA'NR % 312ar PEI CORPORATION{10 3gel(yI4'ARTNER,SHIPQ#) u },lCQ ) 1 - • COMPANY NAME) .3-ecefiy�/�I�+ 511{-1 ADDRESS I erillac `AMr 14.7.4 it i- /Y,0 I CITY wrjr°art (STATE IEZ3 iff'3 0 . 9 - q Ter .517,-311P-- Yg • FAXr -JFear/(CBL$Y &.2grf(EMAIL {1f- 'A O _ ••, xa*. /i,. . -_ . • . . - IOU piahed raw:whpe bhummrre mainalinvengumencaftpmuipao1this S inhere the raiaraurowmWoamrmbtttJwzYre wins MomummrnimbP•insa Co wthkanaNmr httiabaaaddbwtatdiddeWmemnrwnganareasCaMe asie4tMNapdatsetat wawa*mtaaxarpma¢fl bi dais mrararWerkemthe tit bamBbaetOrb. providdthv aacbaaemenrpedastee heltaeSmhbhepamrdmthe=part ad a{teymed tmdmesuurptemba Iscapiejthatrapectergoll Bat maim mvmYaahitat=ta Oae vy ad+epadartnEaatirtaeddiam®rp®hradmp¢mp Bataybm'm4dabs addrwetemtre rdeamdbt proyldabriatrasecrxecain. b 5 - _y-/‘/(('