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Home My WebLink AboutBLDP-15-000645 MAP : A. . sCs, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK j= CITY ` I Man MA DATE �.7 F+ERMIT# P,c G G(O LI ' OWNER'S NAME C I n!re ^,q I JOBSITEADDRESS �%QC,�i'�� IIIU(/'Cti�/ P OWNERADDRESSI I Tit Ob)7.75-37ao2IFAX TYPE OR _ OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW:D RENOVATION:El REPLACEMENT:0 PLANS SUBMITTED: YES 0 NOD FIXTURES 1 FLOOR—. BSM 1 2 © 4 5 6 7 8 9 10 11 12 13 14 BATHTUB a a M a IMS a a_MR MIR a MMS_MMMIMMIA;AAAI CROSS CONNECTION DEVICE MMMT Nt MMI a aa S er a MMI a a a a:a DEDICATED SPECIAL WASTE SYSTEM MMM Mme NM a,M IR AIM a_MMR 11011 111111 M a IIIM a�.a DEDICATED GASKXUSAND SYSTEM all MMI NM MMR a a MM I MMR MMMT RM int_MMI NEI M .MMR I.iaqn1allIMINIII MMR MMMT a a a IMM;a S a a a S MMR INICIIIIII DEDICATED GRAY WATER SYSTEM MMI MMS MMINES MS MMM;MMR MIS MMI MMI MMI S 0111•1111111 taG\ra:rt;yc. i i ii:„ l S a 1M Mt S'.l a I Mt NMI PIM MK SS DISHWASHER MMI IIIIIB aMEM_aaaaaaaa IIMM NM DRINKING FOUNTAIN MMI P_MM I NM ;a n NE_Ml MK.Min..111 MMI S FOOD DISPOSER MMI pm pm Footna MMI loill_MM<- a a FLOOR!AREA DRAIN • M MMI a ma me MMI a—a MM a at MME a a ' r' INTERCEPTOR INTERIO' MMI a..PM NM_MMM u MMR MMMT a._a Mil_a.S MMM(MMMT KITCHEN SINK MMI_M aPma mgownmkt amPmmnor aR LAVATORY NMMMMRa,aMK PIM aaaaaaaaa • ROOF DRAIN ININI PIM.a_MNa S MIN,MIaaaPIM aMI NM SHOWER STALL PIMION a MI,MM MMR SI MMS MI MEM a aa SERVICE!MOP SINK MMI Mg MIIC.PIM S a MMR_a MMS W M MI a MI POW a TOILET PER IM/,JaXIII aPIM AMS_aaaaaaSIAS URINAL MM.MMIMMWaSIM a_aMINMMNaaMIX TIM It""- 1 MD _ �MMI MMI MMM MMI as MMR MIK MMI MMR S 111111111.101111 SI MMI ICt:L--. 'C, psi"X M Dil1a a MMI MMR MMR a MMR MMR_AAAI MMI MI MMR MMM MIMI.MMR MIN ILLuassAirdaunameonlIPM111 MMS MINI PIM MIN MI a n MMI MI S a a a a M IDErlatta/WAMIlli IS NS RMI!MOW MMMT_ISI MIR P1111 MMR 1•1111 NM ma air umM 11111.4111WAllitilliallillM ILMI a aMSS_a a s a a a a a a a .Sss.OMmaaM_aM IaSaaMIS_ Mantuii.aenEyl irimmoaiMMM a SIMS all Mt MMM MMR MMI Me M MN MB MMINI a !WIA� - INSURANCE COVERAGE: I have a current Bath ttv insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES Yr NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABIUTY INSURANCE POLICY Lee OTHFRTYPE OF INDEMNITY 0 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 0 AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that a1 of the details and information I have submitted or entered regarding this application am true and a aaccccurate to the best of my knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be In With ynce 7tith ell Pertinent provision of the Massachusetts State Plumbing Code and Chapterap142 of the General Laws. . PLUMBER'S NAME V211,n m('1711 e- ILICENSE# I)bail SIGNATURE MP lla JP D //t� CORPORATION I ' 07 r. PARTNERSHIPD# /� I LLCQ# COMPANY NAME, ;� Mc fie fir.11.. " Ir, 1 ADDRESS II liar , PiJ ( CRY W. Yoen.ov-VA ISTATE YJ1 BPI 02.473 I Tal (5o0ni- 455.4 I FAX 6of`r90-s1I CELLj EMAIL I - I !� . f rl . ft)C711 crit- G/-5-/r t/3.t/11 • .