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HomeMy WebLinkAboutBLDP-19-001146 • yg.' MASSACHUSETTS UNIFORM APPLICATION FOR APEIRDAITTOPERFORM-PLUMBINGWORK - 'ft s y ;,=z CITY) t "Anna cc/7`h i MA DATE) p4..,. dp (PERMITS/LDP-PERMITS/10-77-00//q6 JOBSITEADDRESS 19 'P/tn vic J7 ( OWNERS NAME}Dr=w NJc N/Aw2te r 1 p OWRERAo0RESS) S4n-7 ( TEL 9t13-,-SR. FAX) — I • TYPE OR OCCUPANCYTYPE COMMERCIALQ EDUCATIONAL 0 . RESIDENTfAL1 PRINT CLEARLY NETiCI - REIOVATIODE0 REPIACEMENta :MANSSUBMRTED:YES© NOM— FIXTURES 7. FLOOR— - e8M i 1 2 9 4 5 8 ) •T 8 9 10 11 12 13 114 BATHTUB - • sm4 smiriM rmaNI > _ c i CROSS CONNECTION DEVICE - EIlialinellinneirallrialaran DEDICATED SPECIAL WASTESYSTEi i•,ai_ 0a . !D.__ DEDICATEDGASIOIUSANDSYSTEM 'IIIIIIIi61 I i11o'eII JU181[fil 111[kI1 iR_ rminintSl : I DEDICATED GR8E SYSTEM ~ . � ' r 1' t T sIn DEDICATED GRAY WATER SYSTEM iail 'ImEIs� l5j' yam FS . DEDICATED WATERRWYC SYSTEM O - .=I i a h n _ DISHWASHER • esi ; EI. I1 DI_;!I jU 1 %I it S ! FOODDISPOSER NI 19 J 'it zT U u MAINS FOUNTAIN . .. flfl1 { I FLOOR/AREA DRAIN a — �t`E •. �. •. KITCHEN SINK g� _ _ ---on qSHOWER STALL 101MIz SERVICE/DIOP SINK I�°l� lil�i moo � IIIIM aPsltlt�l[QA URINALr = ymin 5(\C19 WASHING MACHWE CONNECTION fL�I��I . • I_ it....,,,,.... : &Jai, f Q0,,, IOTHER WairaSima , h fair ' 41 / r N tI • - i i z LL 91 INSURANCE COVERAGE: I have a cun'entflablIkv Insurance pollcybr Assuhstaritial equivalent which mem the rerphernents of MM.Ch.142. YESErNO 0 IF YOU CHECICEDYES PLEASE INOICATETHETYPEOFCOVERAGE BYCREC1UNGTHEAPP[:DPROATEBOXBELOW IIABILITYNlSURANCEPOUcY[J • OTNElTYPEOFrnIOSAJ.DYII BOND[4 • • OWNER'S INSURANCE WAIVER(am aware that the licensee does nothavetheJnsl8Enbe coverage required by Chapterl42 of the Massachusetts General Lan and that my signaler!on this permit application waives this requirement. • • • CHECK ONE MY: OWNER 0 AGENT 0 SIGNATUREOFGINNER ORAGM' • - I hereby certify that all at the details and intonnermn I havesubmted orentered mgaNhigtblsappticafon maims and accurate tothehest of my Iamv4edge andtratallplwnbingvmdcandInstalaUonsperformedunderthepaintffiuredforOdsapplcatonrillbeincompliance rah wtth an PerffnentpmvWan of the Massachusetts Slats Ptwnbtng Coda and Chapter 142 of the General Lem. - PWMBERSNAMEAM ,. [/h Cti; I44EG••Df4.tb tT� ILICINSEa[31 • SIGNATURE MPr 13Q CORPORATIONi231 3Gfq/•Y�PARTNERSHIP®# }, LLCM— • COMPANY NAME ,7 G,-9un4rtyilic -qADORESSkerN ArtftA7SSJP" 22 J`pvr-�/Yti i l CITY ,a -t- (STATE1 /V4 1 W 0 Y9 • 1 TEL Sbl flfl ( i . FAX „IrMMN CELL,�PrS-ap nel MAL /'*i- 'sb.0 •A two tom .. ' gsarasteromshosekt,amsentematatutbspeethatenteattapisr4M n ds aiavwhnmWieeLmeaemvsmnvvamblemmsvmwm�r arsymemazdeamNMoe.bci@amnm.em=eammvpmemam um ymm itiratEffim & bsmySthetas= hamaedbdassaasaalmmat RsAmrnma*magus haee .d&apeeerta rain tat* dbitT=mepmacro tharpsentavtenforpareerradardaternaatzealinfrentalisitazteent awyfdm4thnbpa +habeea+warcate du=medarpmSddbtimtetegab: . , • try .11