HomeMy WebLinkAboutBLDP-15-000607 .,-- a�f CITY vMirnc,lffln 1 MA D 2J
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4� --•� JOBSTE ADDRESS' /1 (h ill\'J f11I M 'MOW
CI II E MINERS NAME Sohn YY)cii kil3
1 OWNER ADDRESS_ cvV✓s I TEL FAX
‘6 TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL$
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CLEARLY NEW: RENOVATION:0 P.E LACEMENT:0 PLANS SUBMITTED: YES 0 NO o
ARES 1 BOOR-' BSMT 11 2 I 3 4 I 5 3 7 3 9 1 10 I 11 I 12 I 13 I 14
BATHTUB I I I I
CROSS CONNECTION DEVICE I I I
DEDICATED SPECIAL WASTE SYS I I I I
DEDICATED GAS/DIUSAND SYS I ( I I
DEDICATED GREASE SYS I ( I
DEDICATE)GRAY WATER SYS I I I I
DEDICATE)WATE2RECYCLE SYS I I I
DRINKING FOUNTAIN I I I I
DISHWASHER I I I
FOOD DISPOSER ( I I I
FLOOR/AREA DRAIN I I I I
INTERCEPTDR(INiEPJOR) I I I •
KITCHEN SINK I I I I
LAVATORY:-. I I _I - I I
ROOF DRAIN' I I •
I I I
SHOWER STALL ( I I
SEER VICE 1 MOP SINK • I I I ( I
TOILET 1 I I I_I I I
URINAL
WASHING IJLACHINECONNECTION 1 7 I I I - I I I D
WATRHEATER ALL TYPES I ( I I
WATE2PIPING I 1 _ 111 9 �f-
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• INSURANCE COVERAGE:
I have a court BabSiiv Insurance policy or Its substantial equivalent which,m the requirements of MGL Ch.1C Yesa No❑
IF YOU CHECKED YES,PLEASE INDICATE E THE TYPE OF COVERAGES?CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY)2 OTHERTYPE OF INDEMNITY 0 BOND ❑
OWNER'S INSURANCE WAVER I am aware that the licensee does not have the insurance coverage required by Chapter 142 of I
Massachuse is General Laws,and that my signature on this permit application waives this requirement
CHECK ONE BOX ONLY: OWNER 0 AGENT ❑
Signature of Owner or(Owner's Agent
I hereby certify that all of the details and information I have submitted (or entered)regarding this appBcafion are true and accurate to
best of my Knowledge and that all plumbing work and installations performed under the permit Issued for this application will b
compliance with allPer-nest provision of the Massachusetts Slate Plumbing Code and Chapter 142 of the G ..
PLUMBER NAME An rl rULy S" , NO 1-5f;4/ • SIGNATURE • /
LIC# aFs.3 3 wP,E1 JP❑/ CORPORATION (# 1165 PARTNERSHIP Of LLC ❑#
COI�f MYNAME Aril' . fCl�f,,m •c of 3-24A. ADDRESS 3a. ,. of., !. A1/
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