HomeMy WebLinkAboutBLDP-18-006923 .� MAP. PA12tee r' 16EY nisi/Igo a#
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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JOBSITEADDRESS j2ICcMA ;IA-e22A IOWNER'S NAME Am4Neon (5ar�r-n e
P OWNER ADDRESS I I TEL 52t 716 6-3121FM
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL a '
PRINT PLANS SUBMITTED: YES® NOD
CLEARLY NEW:D RENOVATION:n REPLACEMENT:0
FIXTURES 7 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 0
BATHTUB IMICI PINI NSISS 11,11.1 ='WON,
CROSS CONNECTION DEVICE 1.1111a1.1.111.1101.110.11SIIIIIIMANIPISIM SIIMIL
DEDICATED SPECIAL WASTE SYSTEM IIMISSIN S r1 .0IC�11110,1111.11M,WI
DEDICATED GAS/OIL/SAND SYSTEM ScelISiIiSOIN ' ISSrKISS'
DEDICATED GREASE SYSTEM 1111 ''` 111.Jn .1111SIMIISOI
DEDICATED GRAY WATER SYSTEM IsleIISPII0111al SIINg ,
DEDICATED WATER RECYCLE SYSTEM i _l [, �M'C�'l��l �tl lI �W�ONSISIMIONin NS ,�s'
DISHWASHER Mg S '
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DRINKING FOUNTAIN [ -:�� S.
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FOOD DISPOSER 5I '�1�� .1SW i si M11
FLOOR!AREA DRAiN INI ISi OIMUIMt ilia.. `___ OM
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KITCHEN SINK MCWOISINII illtIONIM:SSSMII 011.10011 I=
LAVATORY ilin/a 'I i 'tl 1411 SWAMI
ROOF DRAIN NIS MtlfS[ S'LZI='aIaLla
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SHOWER STALLSII ;sI IISS SFOI W S frlI II 1S1
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SERVICE I MOP SINK � i�l�� ��1� �R 111LI1`� .R+ lital
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TOILET 04111iJ 1111111 i .II MIS:
URINAL 11111110. I ,.110in afet 9�R i�S
WASHING MACHINE CONNECTION Plinla1S1�SRIIIOWk. SONIOtsLllllt'a
WATER HEATER ALL TYPESMSr_«' a t' � 'I��'111��1Ii fi
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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 4 NO 0�i
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW iIII
LIABILITY INSURANCE POLICY a . OTHER TYPE OF INDEMNITY D BOND 0 c "�/l/
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 9 AGENT D
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 all plumbing work and Installations performed under the permit Issued for this application wig be In compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 rif the General Laws. I- _ (���,` A `�_
PLUMBER'S NAME IRGBr`IC�y'WALdtO•'P'U IUCENSE#II9ln1 I�1`— " SIGNATURE •
MPD JP t4 P cby ' CORPORATION:#LL_ _IPARTNERSHIPD#I ILLCD# - I
COMPANY NAME,Li j.a�f1/4t�'.j '-4- I ADDRESS nrgya ..► ►--fi
CITY If/�Trll►/teT�rt•_•rl>•+ l1111111
STATE NA— I LP 'WWII TEL EVEIr anaSTJrSI
FAX I I CELL— EMAIL ICIrm S. S o . _il •
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY • FINAL INSPECTION NOTES
Yes No
oe /L O /THIS APPLICATION SERVES AS THE PERMIT ❑ 0 / PJ /o
(�//��iLLJPERMIT# 0/'/ f/� J�C
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a FEES oPLAN REVIEW NOTES j/,
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