HomeMy WebLinkAboutBLDP-19-000197 •
AMP: PAR Ct C
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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I CITY 4`a T74-I d NthITI-f-I I MA.DATE 1-1—Th? PERMIT# bP I`7 X 000�I
• JOBSITE ADDRESS 100 C ji'-P ia•I VJ1H I OWNER'S NAME C 4{I K`Knueff
P OWNERADDRESS I TEL-7$(l- -S5y¶ IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Q RESIDENTIAL
PRINT
CLEARLY NEW:Q RENOVATION:43 REPLACEMENT:Q PLANS SUBMITTED: YES Vi NOD
FIXTURES 7 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB I i
CROSS CONNECTION DEVICE —
DEDICATED SPECIAL WASTE SYSTEM PIIIMESSEOTOmilaarlialISMICIPS,[
DEDICATED GAS/OIUSAND SYSTEM 5f h , al;It.1.011.20. '.s 1 .a:� ,�ai
DEDICATED GREASE SYSTEM —I—a—ras,S S-- —�-55i
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DEDICATED GRAY WATER SYSTEM ' i�� ;�I���j1'��,, �� 1
DEDICATED WATER RECYCLE SYSTEM SSISali Maj..
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DISHWASHER TIMIklsi/ •111 SaaIATIMI:
DRINKING FOUNTAIN MMESSOlinfelaikiltaltaiNOINISMS
FOOD DISPOSER MISS Wi11 [J� iutr_isTI , r .
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INTERCEPTOR INTERI (�ii r r�jPI i�
�OORO/RY Witt AREADRAIN -R= r 'e� L e
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ROOF DRAIN — 5,WI-IaIWWflE tilL11
SHOWER STALL - - AYt,ra f�R STS aWa�f_ SIMISII INTO
SERVICE IMOP SINK (1lin ][_� ���u—s;allk :
TOILET IIJ ill IS ,C Sl -
URINAL 1111.ilaa
WASHING MACHINE CONNECTION �; f tai S;m is a s',
WATER HEATER ALL TYPES ■�� ( i1■�;IwAI[ [� ,1■�l[i
WATER PIPING
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INSURANCE COVERAGE:
I have a current liability Insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES fit NO Q
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY Q BOND 0 •
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: OWNER Q AGENT Q
SIGNATURE OF OWNER OR AGENT '
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 Massachull setts State Plumbing Codework and ations and Cpptter�performed42 of the General
nLaws.�for this application Albe Inbecompliancewith all Pertinent provision of the
PLUMBER'S NAME c '6 I U.Tce-C"n( d "�� tscP.o ILICENSE# `rhos/ I CC SIGNATURE •
MPD JP a fDroP ' CORPORATION Q# ' IPARTNERSHIPQ# ]LLCQ#
COMPANY NAME I( C f t rke P-4--G( J ADDRESS
CITY '0 .\lei !`A•ioJ ("41 ISTATEaZIP 0 '2-6 6 r I TEL ?>7 "FM ?" - I
FAX CELL I EMAIL
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FAX . 711 c .c� " cto acia S vt-4 /L• Con, I
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
0/7.. THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ //A ' 'A/6re,
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FEES PERMIT# A t i `O//-
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fall / 4/71
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