HomeMy WebLinkAboutBLDP-15-000047 MASSACHUSETTS UNIFORM APPUCA I ION rUKA rtrcrmi I Iu rmrcrurtm rLI vv-1M\
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V JOBSITE ADDRaS 7 5 fwrg �Jc. OWNERS NAMEgrl SC4/0
POWNER ADDRESS ( TEL t Z 94 7375 PAy,
TYPE OR. OCCUPANCYIY'E: COMMERCIAL
EDUCATIONAL ❑ RESIDENiIAL[(��
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CLEARLY ` 0 PEE'ENOVATION:NEW:0 RLACEMENT: PLANS SUBMITTED: YES 0 NO 0
FXTURES 2 FLOOR-. BSI 1T 11 I 2 3 1 4 3 8 1 X 8 9 I 10 11 i I 12 I 13 14 _
BATHTUB
CROSS CONNECTION DEVICE I I
DEDICATEE)SPECIAL WASTE SYS I I
DIDICATED GAS/OIUSAND SYS I I
DEDICATED GREASE SYS I
DEDICATD GRAY WATER SYS I I
DEDICATED WATER RECYCLE SYS I I
DRINKING FOUNTAIN I • I
DISHWASHER I
FOOD DISPOSER I
FLOOR!AREA DRAIN I I I
IN i ERCEPTER(INTEPJOR) I
KITCHEN SINK I I
LAVATORY__
ROOFDRAIN- I
SHOWER STALL I I I
SERVICE I MOP SINK • I I I
TOILET I I • I
URINAL I I I
WASHING MACHINE CONNECTION I I I I
WATER HEAIT .'AL'TYPES I I I I I
WATER PP G -_._._ '
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I I I I I I
INSURANCECOVERAGE: r-,�
have liability insurance policy or is substantial equivalent which,meets the requtramerts of 64GL Ch.1C {a Yes No 0
W YOU CHECKED YES, PLEASE INDICATEETHE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ['y OTHEER'MPE 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 ti
Massachusetts General Laws,and that my signature on this permit application waives this requirement
CHECK ONE BOX ONLY: OWNER 0 AGENT ❑
Signatire of Owner or Owner's Agent
I hereby certify that all of the detafs and information I have submitted (or entered) regarding this appfcation 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 be
compliance with all PerEnent provision of the Massachusetts State Plumbing Code and C `r 142 of the General Laws.
PLUMBER NAME g7.//� 1r • . SIGNATURE ( `—Z---
UC# /(0O6% 1JIP pQ 20 CORPOFth110N ❑# PARTNERSHrIP ❑t LLC ❑#
COMPANYNAME (&�e 1 4,�b•� f irf4k4A ADDRESS: /rt sh/ypn D '
CITYi�vrct% STATE MIS" ZIP OZ-61C BAAL • �r^�.1,- /0 r�Crr a,-l ca.,.TEL .59a �((, -73)r GEL. FAX t✓/
VII,A IN PE O► ►OTE
ROUGH PLUMBING INSPECTION NOTES
TTTT9 PAGE FOR iNSPTLCTORURE ONS
Yee No
. 9 :• C: 0 S- -R 91 ntut 0 0
FEE: $_— PERMIT,/____—
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