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HomeMy WebLinkAboutBLDP-15-000208 /VI.- - jWZ00 t cm' Q r Th OU t IlMA. DATE 7 Q3 Itl PERMIT !"/5-1 O 1�- JOESITEADDRESS U 1 © I vl 717 St - OVJNERSNAME &Ss Niiver C11 Cll pOWNER ADDRESS if 014 nein $ ( FAX TYPE OR. OCCUPAJJCYTYPE COMMERCIALL EDUCATIONAL ❑ PESIDETRAL❑ PRI CLEARLY NEW:❑ P,ENOVATION:0 RE,' BM REPLACEMENT:0 PLANS SUII IED: YES 0 NO 0 FIXTURES 1. FLOOR-. BSIT 1 2 3 14 H 6 I 7 I I; 19 10 I 11 I 12 I 13 14 BATHTUB CROSS CONNECTION DEVICE I I I • DEDICA7dj SPECIAL WASTE SYS I I I DEDICATED GASIOIUSANDSYS I I I DEDICATED GREASE SYS I I I • DEDICATE'GRAY WATT',SYS I I I DEDICATED WATERRECYCLE SYS I I I DRINKING FOUNTAIN •I I I DISHWASHER FOOD DISPOSER I FLOOR!AREA DRAIN I II EERCtrIUR(INTEPJOR) I KITCHEN SINK I LAVATORY:-. I • ROOF DRAIIC SHOWER STALL I I SERVICE/MOP SINK • I I TOILE I I I URNAL WASHING MACHINE CONNECTION I I I I WATEtMEAIT ALLTIPES ,o - I I I WA;stPIPING III I I I I I I OTHER I I I I I I 4 I I I i I I I I I • INSURANCE COVERAGE- I have a current liability Insurance policy or is substantial a equbraleiatwhich,meets the requirements of MGL Ch.142 Yes,26o 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CI-EECK:NG THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY lE OTHERTYPE OF INDEMNITY 0 BOND ❑ OWNERS INSURANCE WAVER I am aware thatthe licensee does not have the insurance coverage required by Chapter 142 of t Massachuse s General Laws,and that my signature on this permit applicaton waives this requirement CHECK ONE BOX ONLY: OWNER. 0 AGENT 0 S••nature of Owner or Owners •.ant I hereby certffy'that all of the details and information I have submitted (or entered) regarding this application are true and accurate to best of my Knowledge and that all plumbing work and Installations performed under the permit issued for this ap. -r on will bi compliance with all Perfinentlprovision of the Massachusetts Slate Plumbing Code and Chapter 142 of,relit �-' 1�: PLUMBER NAME 1 / ` ex I3 r'a SIGNATURE - el t f1- # 15 ( C21 ATPt<JP❑ CORPORATION 36 if PARTNERSHIP ❑# LLC Of COIJPANY NAME B rac A 61-05. ITN ADS 1107 5 r fed'5 h; 11 IU fr3 OITY 14- ( a 1-'1 t is STALE Alit 72 040 sw. TEL771-'l8)- 9®$/ CELL FAX RECFIVF_D • Soyy r5o _ YN(J,u JUL 23 0 k0/141. got BUILDING ARTMENT BY