HomeMy WebLinkAboutP-13-129 ('aa ismer 'So o776
L t , )„ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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e.3 1�J; CITY)'Lye,..l ofl MA DATE Ao PERMIT# f l8 727
JOBSITE ADDRESS if.2( ' -,)LGA1.4A ( OWN R'S NAME se tom_
P OWNER ADDRESS / , /i • ii, ,. i TEL 2� .//D ygJ FAX l
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALR]
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENTEI PLANS SUBMITTED: YES 0 NO`i]
FIXTURES 1 FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BAT
DEDICATED SPECIAL WASTE SYSTEM y I .0
DEDICATED EDGASIOIUSANDSYSTEM f I ' ii .� iCROSS CONNECTION DEVICEi r ii `li
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER 9�1'STEM I II -11 ir
DEDICATED WATER RECY4gE SYSTEM 1 I 1 - T. '�r
DISHWASHER \ L 1 I
DRINKING FOUNTAI C ' z '1 I i I i �� 1,_�'21,_.2
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FOOD DISPOSER 111 f• r.r
FLOOR I AREA DRAT E� o ' �J
KITCHENLAVATORY ' e ,r. r . --r1� „-;
SINK rn in r r _ � �'
INTERCEPTOR INTE' 4R .. _
Get I '.tom . .•.. r_:
tom' f � i �I x � ...Ili,-
ROOF «,
ROOF DRAIN T , I I Ir p ,
SHOWER STALL LU---- u l ' I
SERVICE I MOP SINK ce 1-----1,7, i I I `11, —_rat, a—. la.acl--_.
TOILET
URINALa �
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WASHING MACHINE CONNECTION 1,5 I— MS ins r s 1---!I ---11-
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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 0 NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massac� , eral Laws,and signature on this permit application waives this requirement.
i i /'?// CHECK ONE ONLY: OWNER ® AGENT ❑
SIGNATURE OFR OR AGENT
I here.y certify that all of the detail d 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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER'S NAME QGrL/r,y,�'�', r,, , LICENSE# rrra, vV SIGNATURE
R342 JP El CORPORATION❑# PARTNERSHIP❑# LLCQ#[ ---]
COMPANY NAME 1/.4.44,,Ckcac ADDRESS 1
CITY ,'?IJ ISTATE�a ( ZIP a/Si7 TEL Sap t39Yh61. - 1
FAX I CELL EMAIL