HomeMy WebLinkAboutBLDP-19-001643 MASSACHUSETTS •
1UNIFORM APPLICATION FOR
A PERMIT TO PERFORM PLUMBING�"D] WORK
Lilo CITY YAkmot Y1 MA DATE Il l/ t PERMIT#/iJ&V"cV/o
JOBSITE ADDRESS J 1 n aiciA f A 1 ��f3"ACAAI aLI) OWNER'S NAME fAV i L) SUEe
OWNER ADDRESS P4 0 Cy i A/ P4t'CA/ F-a TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL[
PRINT
CLEARLY NEW:V RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO[E—
FIXTURES 1 FLOOR-' 6518 1 2 3 4 5 6 7 6 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOILISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM •
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY - R-EE W I
ROOF DRAIN "1 �
SHOWER STALL _ _
SERVICE/MOP SINK o[L 1 R 71118
TOILET JEt '
URINAL G�+�1 �
WASHING MACHINE CONNECTION �-=z--L1P: T _
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 p''NO 0
IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY OTHER TYPE OF INDEMNITY 0 BOND 0
OWNERS INSURANCE WAVER: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
LU 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 m Imowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance • rent provision o
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME I/i&611_,+0 £ L✓'A LICENSE# 3I3q6- 1G1dATU�Fr�
MP 0 JP[rK. // CORPORATION❑# PARTNERSHIP Q# LLC❑#
COMPANY NAME S/L✓4 PLVMb,nJg eAk ADDRESS Es Subb„ky lav
CITY I4 YAAJ AJ ` S STATE(n 4 ZIP 02C:0 1 TEL
FAX CELL-774/46C 01 7 EMAIL„ /
412,C
,2401 2-(1(vrhi