HomeMy WebLinkAboutBLDP-19-1333 oir 'lid el°1T-) \)
f', MASSACHUSETTS UNIFORM APPLC ON FOR A PERMIT TO PERFORM PLUM:I GG WORK 29
_a-Z CITY yAociv in TN MA DATE 9— y'A "—�I
/C( PERMrry940 —OO/95
JOBSITE ADDRESS l'it/ ' irA AvF S4 y OWNER'S NAME penso &SOL J
POWNER ADDRESS s/JME TEL15'11Y7y68Yi-7FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL p—
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:[2 PLANS SUBMITTED: YES 0 NO j/
FIXTURES 1 FLOOR-. ESM 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 .
I ROOF DRAIN R E C+
{ SHOWER STALL an "" .
I SERVICE/MOP SINK TOILET ea OA 20191
i ob..-
URINAL
E1URINAL _
i WASHING MACHINE CONNECTION OA-II n - OE..Hi • -i•T ., -
WATER HEATER ALL TYPES ./-8or1 fR v- # 6v _ . '*
WATER PIPING COMKp
OTHER
INSURANCE COVERAGE: ,_,/
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO L2
IF YoU CHECKED YES,PLEASE INDICATETHETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 0 BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
1 Massachusetts General Laws,and that my signature on this permit application waives this requirement.
•2 2�;� "" CHECK ONE ONLY: OWNER 0 AGENT [�
SIGNATUIE0 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 my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / -`
PLUMBER 1 • i•• LICENSE#1767 . S cT RE
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MP 0 JP Q CORPORATION❑# PARTNERSHIP Q# LLC Cr
COMPANY N'1' ADDRESS SS MORA/Lk/1 a LORD'
CITY A,fA/N/S STATE Mg ZIP 0, 63R" TEL SOF-VC- -12-Y3
FAX CELL EMAIL / r
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