HomeMy WebLinkAboutBLDP-16-004344 /'? A P4/2ce, / w56
. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY Town 06Denas •� 0 ( MA DATE /-22-ZG> PERMIT#1 P--P-16-CO 09V
JOSSITE ADDRESS -7A/a 1,aQ (orf p.,t J OWNERS NAME t A2 nt)Q>•to
• _ OWNER ADDRESS __ _ - _ J TEL • FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 0
PRINT
CLEARLY NEW:D RENOVATION:D REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NOD
FIXTURES 7 FLOOR-. BSM 11 2 1 3 4 I 5 6 I 7 I B I 9 . 10 11 12 I 13 I 14
BATHTUB 1 _ ,1
I _ �l._- '_9N _NI_ SII tI--- i1,� h_ TN _-,t_—i
CROSS CONNECTION DEVICE ,--s. _:II _ i. _IP. I1- __i 1I,_ __
DEDICATED SPECIAL WASTE SYSTEM `_It IInII $ dI
DEDICATED GAS/OIUSAND SYSTEM ,,,,T.i' I91 ill 1_11 __IL t Al___AI- 117
DEDICATED GREASE SYSTEM _,F—N_IN _'I__ __III__ i+.__ll III_II _41._:�I___`-
DEDICATED GRAY WATER SYSTEM ,-.7117711 i l _ Ina I_NI III I1 lb . _ Ilp . ... .(III -
DEDICATED WATER RECYCLE SYSTEM . 1 I - _ ._ r._ i, lift"_II AI _, IN-�1 ___ II____ III^
DISHWASHER _t it 1 1 #ThF4 !Ip l: I I II
DRINKING FOUNTAIN i -__JI 4I :E IIIA _DIL_ fll___._!NI_II_111-3II�N��1__._,II
FOOD DISPOSER to [-•--1 j4 J,r IN1 - 1,1 III III NI dN 1N NN
FLOOR/AREA DRAIN __... l I1__ i, _iI1, - 1_ICAI 'L__ I .-__ I
INTERCEPTOR INTERIOR ,,,....-_,01___I_II_ _ I__II _if�5,=��I _i1II__III ,�-1—
tssrSR_1 ,��OMNILEI-
LAVATORY II 1 _ I__ IIT _ _II__II L-.____ -__ill _II
ROOF DRAIN - I-IlII I__I�T
. •SHOWER STALL • I f I 'I ' • III 0-7111-1i I —III ( III Cr
SERVICE/MOP SINK • , _91 _ LCD _ Ll I In-lL___II- 1I—:_
•
TOILET
URINAL 1. _ I I..._ 'I..._._' 1117-1 . .._I'I 1I_._. II __Illi 11-711, _ .__
WASHING MACHINE CONNECTION MaHMI ®q II -f I-- Int _U I 1.77-1. _ 1
•
WATER HEATER ALL TYPES I ._ Ip I, __I II f II
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WATER PIPING l �I 1 �I�II -�1,,.,_,-II�'pl�II�I�H „ II ih_r__,
OTHER I_ - ., Ir Ill III 1 �I II .. I� II iC
_ • O._ ._!_III_ I i�__ IlI__1- 1 it 11._ f. t_�N_�-
Crn I— —t I_ r--yl�i1 __I=_ _il_=VIS_I C
INSURANCE COVERAGE:
I have a current liability Insurance policy or its substantial equivalent'which meets the requirements of MGL Ch.142. YES m1I0 0
_ _IF YOU CHECKED YES,PLEASE INDICATE THEPE OF COVERAGE BY CHECIONG THE APPROPRIATE BOX BELOW. ... _ _ •
LIABILITY INSURANCE POLICY j5' OTHER TYPE OF INDEMNITY 0 BOND ED
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 compliari a with—atl�2rtinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. . ry]
PLUMBER'S NAME £ t 1 At/N-EC S (LICENSE# PT/21W ` SIGNATURE J ATURE .
MPO. JPD CORPORATIONO#--PARTNERSHIPD#L'LL'CO„Mos
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COMPANY NAME 03 /Y/47;tf 'w`d I ADDRESS 57a Qp �S iszt Jam- fa(i, , .
CITY Dcv,u STATE MIA ZIP IQ . .1 TEL 6l7-gCft-Oa 2 _ .I
FAX CELL . , EMAIL
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