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HomeMy WebLinkAboutBLDP-15-000026 —`--\ MASSACHUSETTS UNIFOP.M APPLICAI iUN rUtCA rnecnni I 1 u rcrerurtavL rL_-nvict rla vvLJru. ` te yaNr , tti .7011-f P�= ©ol cm( nr. � / MA DATE �' ��— PERMIT o 1 JOESITE ADDRESS /./ /1' r er s e 1e OWNERS NAME E H e vie/ z L' OWNER ADDRESS SG,,...2... T ELJO 77.L `6fz 5 FAX c�.I :itiil -E OR OCCUPANCYI r E COMMERCIAL 0 EDUCATIONAL 0 RESIDcJ�IAL[2' % �, PRINT W ;,LEARLY NEW:0 RENOVATION:111. REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0 V Cu ), ''I -a'1 FLOOR-. I SSW 11 2 I 3 I 4 5 6 1 X 3 1 9 1 10 1 11 I 12 13 14 BA,.HTUB `CRDSS CONNECTION DEVICE 1 1 I I I I I I DEDICATED SPECIAL WASTE SYS 1 I I I I I II- DEDICAIr GAS/01LISANDSYS I I I I I Ay' DEDICATED GREASE SYS I I I I I • I IJ DEDICATE)GRAY WATER SYS I I I I I I DEDICATED WATER RECYCLE SYS I -I I I 1 I I I ��/ DRINKING FOUNTAIN I I I I • I I 514'4 DISHWASHER 1 I I I I I FOOD DISPOSER I I I I I I P11J11•FLOORIAREADRAINCPI UR(INTERIOR) I I I I I • I �c5Tt� KITCHECN SINK I I I I I I _. LAVATORY-_. I I I I I I I , I I I I• CRnW SHOWERSTALL I 1 /SERVICE/MOP SINK I I I I I I I TOILEE I I / I I I I • I { I URINAL WASHING MACHINE CONNECTION I I I I I I I I I I WATERHEATERALL TYPES I I I I I I_ 90 01 WATERPIPING I I / I I I I I I I 0o 1 OTHER I I I I I I I I I m I I I I ,n I I I I 1 I I _ I_ I • • 6� V0• INSURANCE COVERAGE: . J/ �� D I have a currant Debility Insurance policy or is substental equtvalentwhich,meets the requiremeres of MGL Ch 142 Yes 6 No 0 U IF YOU CHECKED YES, PLEASE INDICA i cc/THE TYRE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [t" OTlIZRTYPE OFINDEMHITY 0 BOND 0 OWNER'S INSURANCE WALVER I am aware that the Bcensee does not have the insurance coverage required by Chapter 142 oft! Massachusetts General Laws,and that my signature on this permit application waives this requirement ` CHECK ONE BOX ONLY: OWNER 0 AGENT ❑ I nahrre of Owner or Owner's Agent - • \ r�`1 hereby cerbf that allof the details and information 1 have submitted(or entered)regarding this appUcafion are the and accurata to N, best of my Knowledge and that all plumbing work and installations performed under the permit Issued for this application will be compliance with all Perfnent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER NNE , `�'Gk .r2gDt{'P. SIGNATURE�� d O uC# 13eV IJP[t. IP❑ CORPORATION ❑d So ❑# LLc O# i COMPANY NAME Pick- 6-te Gf V)(re Pe if ADDRESS:.1 o �1�1 a-d-er/ e cr c ('� (h cmr olferr TIte / STATE IM 72ezz6GBAWL • v TEL Sag 7760 `Cr 923- GEL FAX ay r • Fr. . HOUGH PLUMBING INSPECTION OTFS THIS PAONIN PE TO .T� GE FORT 'SPL'C'l'OR UST r Y 9 y N� _ PE / 133 ��, ✓� 4 moi( y�l l� Yea O FEE: 441 $_-- PERMIT II Mit IREEF W IDI-E+S f 1