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HomeMy WebLinkAboutP-13-774 60 , . IMP: PRA eel. : g, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Z-r _ :la, CITY 0177-1", ,f.t 0 a MA DATE I LTJ!3l/3 I PERMIT# f/34--"'77 y i JOBSITE ADDRESS _Ice }'c9nh Vats) 6-/t1 OWNER'S NAME h cvn 6cu'&etl✓S ►-� I P OWNERADDRESS I SAyw� TEL ,may- I TEg J IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL© EDUCATIONAL © /3RESIIDDErmnl 7O PRINT CLEARLY NEW:© R_RJOVATION:01 REPLACEMENT:© PLANS SUBMI i I t1.: YES© NOD BATHTUB 1 FLOOR-. i BSM 14:4(1 3 4 5 8 i 7 8 9 IC 11� 12 1 13 1 14 CROSS CONNECTION DEVICE � t : a--� #,-1 DEDICATED SPECIAL WASTE SYSTEM . -SP —"1�'T t- 11r- -- DEDICATED GASIOIUSAND SYSTEM _ — DEDICATED GREASE SYSTEM _ 1 - —( DEDICATED GRAY WATER SYSTEM �. - -11 -' DEDICATWATER RECYCLE SYSTEM ,, ED DISHWASHERI _ --- DRINKINGFOUNTAIN ___ M, p FOOD DISPOSER y ---S W I -i I—pi+ FLOOR/AREA DRAIN -, -1 ,,,____, INTERCEPTOR(INTERIOR) IJI , _______.......Th KITCHEN SINK L _ I I LAVATORY ! I I—TTi '-----1 i---i ROOF DRAW — ----1 Cl SHOWER STALL SrMVICE/MOP SINK —. �� 1SIS � ,, - TOILET — i URINAL �� .. - -_��� WASHING MACHINE CONNECTION M -f WWATER INERALLTYPES p IN N - 1 L I-1- {� Cl OTHER [ INSURANCE COVERAGE: �y I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Ina NO El F YOU CHECKED YES,PLEASE INDICATETHETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY M OTHER TYPE OF INDEMNITY© BOND 0 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 13 AGENT • SIGNATURE 0=OWNER OR AGENT I hereby certify that all of the details end Information I have submitted or entered regarding this application are nd a rate to the best of my knowledge and that all plumbing work end installations performed under the permit Issued for this appfcation will be in •. ce ' 4: Pertinent provision of the Massachusetts State Plumbing Code end Chapter 142 of the General Laws. PLUMBERS NAME I AI 6.4((4 n 8. I LICENSE# /7 79 7 I SIGNATURE MP4 ,PQ toe 301 (2 IPARTNERSHIP©# LLC D# COMPANY NAME Chnc wm /ugc1 caI1ADDRESSI_g . p-f^I/aah /A// it- CITY_tQ, 'AM 0F^ . . STATE MPI ZIP olJaC j TEL ,raj- Ty4/-7,s'ol J FAX I Ma EMAIL -------- 1161 (c' n r? n nn fP sn6-3sy)r7b 606-C a yie t , t+AY 13 7013 i ) �� . *tcbz 62GOw, it)o y)ntI' cat 1—17