HomeMy WebLinkAboutBLDP-19-002378 DVP : Pic keec : of"-groen 97.
IS, I MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM PLUMBING WORK
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,_.N�• CITY C �__yQ rn o(J�- r—I MA DATE I I n 7/ Sj �PERMIT#�! �1�1'C�?��✓7�
JOBSITE ADDRESS I 0 -EI n1 i-n . I OWNER'S NAMEI�,'An re,,I I P y
POWNER ADDRESS J Tar-na)ala-Clad $FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 9 EDUCATIONAL 0 RESIDENTIALa
PRINT
CLEARLY NEW:Q RENOVATION:9 REPLACEMENT:Er . PLANS SUBMITTED: YES 0 N09
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FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 ,
BATHTUB MI 11•11,1111111111111 PPM'M;111111111111111•11•11111111.1•111,11111R111•1 INSNMI
CROSS CONNECTION DEVICE S
iq1 SaW�ini
DEDICATED SPECIAL WASTE SYSTEM — _ i
DEDICATED GAS/01USAND SYSTEM I
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM _'i
DISHWASHER � _ - ..�.,i 1
DRINKING FOUNTAIN I
R//AREADRAIN ,
INTERCEPTOR(INTERIOR) ,j ', j r 1
KITCHEN SINK MS
LAVATORY . ; - t , I i -
ROOF DRAIN A-
SHOWER STALL y . ,o
SERVICE/MOP SINK L k. . i ...., r 1 , 1(,
TOILET -. . . .,...i..-' I r ...U.
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WASHING MACHINE CONNECTION r
WATER HEATER ALL TYPES _ _
WATER PIPING . _ _ ..I- , . � .i ,f.. �. 1
OTHER L. - ,,-I
INSURANCE COVERAGE:
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I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES DiN0 Q -
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY f f • OTHER TYPE OF INDEMNITY Q BOND Q
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 0 AGENT 0
• SIGNATURE OF OWNER OR AGENT
1 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 ;r nce with ail bn of the
Massachusetts State Plumbing Code and apd Chapter 142 of the General Laws.
PLUMBER'S NAME I IAA):r TA C 13 P I LICENSE# I I &o - SIGNATURE
MP RI JP . CORLL
P0RA11ON0.#;SuC JPARTNERSHIPQ# / CQ#
COMPANY NAMEi., n McBd
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N. r, £
. IADDRESSI Il O Pod'/
C /. Year an, STATE
cm, U % nMg ZIP Da67S
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TEL) (5a7fr) 7it� et 11I/ D
FAX 4ot-ti a.G1410ELL(2ok)3(4•374EMAIL I emC.p1Umb t9 CiOIM!/OtS4 4, 0I'
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1 OCT 19 2010
BUILDING DEPARTMENT
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SO CIC-14--711l ,
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