HomeMy WebLinkAboutBLDP-18-006051 b t ., MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
F . CITYL . /4 _.A ouTir � MA DATE PERMIT#tpt
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JOBSITEADDRESS I7 (7-i,trr /.n. 1OWNERS NAME hrri 4Ori er.Snn
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P OWNER ADDRESS Ia S try in ii Ur tr LivvIorin, 1 TEL IIIIIIIIMIIIIIIIIIII FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL La RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:ef REPLACEMENT;❑ PLANS SUBMITTED: YES❑ NOD
FIXTURES 7 FLOOR-. BSM . 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB I ii I , .. I li
1 i 1 .—
CROSS CONNECTION DEVICE LI . - M`
DEDICATED SPECIAL WASTE SYSTEM I 1
DEDICATED GAS/01USAND SYSTEM Mi1 1 1 ii r - II
DEDICATED GREASE SYSTEM M
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM I ai 1 I i i i
DISHWASHER ,G�[�i �
DRINKING FOUNTAIN II
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FOOD DISPOSER Mr _an — 1 --I- - 'r. --I 1 7- — Tr a
INTERCEPTOR INTERIOR PIM _. ,FLOOR . a" I _ tflUhIIIRRi_
KITCHEN SINK mflhRqflflifl .SHOWER STALL =tinai ,��
SERVICE/MOP SINK SWI ; i I i , MR 11 l ' i OM
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WAURISHING MACHINE CONNECTION IiIiRiiIRiDiii
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WATER HEATER ALL TYPES 10 I
WATER PIPING
OTHER1
=rFMA CE''. . uDPLY II /►�� v I
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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 2/NO ❑ •
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY e 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
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
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 comeuence ea*all n ro Ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME 14.40:r• hi 0136 0)e, I LICENSE# 1 Ibaa SIGNATURE
MPIZI JP ID CORPORATION #02a6cY(, !PARTNERSHIP 0# LLC D# 1
COMPANY NAME Vain (14C r;rd e P4 1. Tnr',. I ADDRESS ,, £ P/ {I
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CITY W. 1/4rn,4viA STATE mA ZIP i da. .-s6i'3 _ . n&' . 4raS
FAX 4os"f90-ti`f4l CELL�093t4.37 EMAIL • ]Cm G pio m h rco rr1 eas4 u I '
AFR 30 ?018 J /. )
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DEPARTMENT /�V '�(/ LR/
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