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Mr. GATE' 1 f i / _ PERMIT fl/ -3G3 I
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rossii'cADDRESS I '�13 Knott 6 71- 1GIM41RSNALEI aLsu1
P OWNER ADDRESS! r S Q,yyt-e_ 11E0305-3 WPX:n— J
TYPE OR OCCUPANCY TYPE ComerIAL 0 EDUCATIONAL 0 RFS'B'TWLL 0
CLE
PRINT
NEW:❑ . RENOVATION:0 REPI cNT:ra----- RAMSUBMITTED: YES 0 NO❑
FIXUTRES'1 FLOORS-, ets l 1 1 2 1 3 1 4 1-5 _ 6 , 7 I 8 I 9 110 11 1 12 13 114
BATHTUB I I r I I I I
CROSS COIN DEVICE j I
DEDICATED SPECIAL WASTE SYS I I I I
DEDICATED GAS/Olt/SAND SYS 1 I I 1
DEDICATED GREASE SYSTEM
IDEDICATED GRAY WATER SYS I I 1
DEDICATED WATER REt1SE SYS I t
DISHWASHER I I I I I I l
DRINKING FOUNTAIN 11 L I I 1
'DOD WASTE GRINDER UNIT I •
FLOOR IAREIDRAIN 1 I I I I I I I
INTERCEPTOR INTERIOR I I -, I '
KITCHEN SINK I I I I
• ( LAVATORY I I OOF DRAIN 1 I I
R5riOWEn STALL I • 1 I 1 I I 1 I I I
SFRVICEITv10i SINK I I I I 1 I I i
[TOILET
URINAL I I I I i • I I I I 4;
WASHING MACHINE CONNECTION 1 I
WATER WATER H ATER E ALL TYPES ' I I I I
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I I I I I I I 1 I
INSURANCE COVERAGE , • .
I have a curves!f abilir v Insurance policy or IS substantial equivalentwhich mists tie requirements of MGL Ch 142 YES N0 ❑
IT you have checked Yom,please indicate the type et covers checking the appropriata boa below. -
LIABILITY INSURANCE POUCY I2 OTHER TYPE 91DEJMNrY 0 BOND 0
OWNER'S INSURANCE WAIVER 1 am awarethatthe licensee doss 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 •
I SIGNATURE OF DytNIR OR AGENT .
I hereby certify thal al of the details and erbraaico I have submitted(a entered)vegan/mg Ods appbtion are titre and accurate tote best ofmy
Knowledge and that all plumbing work and bistafaSa1s performed under the pennk issued for Ids 1 be In emplane v#Th ell Pertinent
povision of the Massachusels Slate Plumbing Code acrd Chapter 142 of the Centel Laws.
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PLUMBER ME:I it WC 0 'e Dn n of luceiseM.11 I cr r 1 SIGNATURE
CONPANYNAM La--O'C'Dn/1 P(vhiy,4- J ADIOS&( ISL Cp, Se(z'rste-moi)-UvutA;g
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MAST6T1� 9oldEYidAN❑ CORPORATIkY❑o r PARTNERS-BP 1Id'❑On 4c0,1 111111011111
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