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HomeMy WebLinkAboutP-15-941 (15 Simpson Avenue) `lo Aa : r . .(S, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _ , 'y CITY[ Y4 QM n crr N —1 MA DATE ilp7 14 FERMIT#/4A �/i''XV94/ JOBSITE ADDRESS I ( 6 c rr Sri r, Ase I OWNER'sNAME tV,'/)i r,m n Fctie t P OWNER ADDRESS r. 6.G. A , I TELI6473)8`64-0064IFAX TYPE OR OCCUPANCY TYPE COMMERCIALD EDUCATIONAL D RESIDENTIAL Er PRINT �{ CLEARLY NEW:D RENOVATION:u REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOD FIXTURES 1 FLOOR-0 BSM 1 ©© 4 5 6 7 B 9 10 11 12 13 14 BATHTUB a a tom,MMR MMMT iMMMI MMMT MI MMR MMR MMMT 1111111 MMRMMMI,M K 1fPdI kYsill.1111 MMMT MMI MMR MMMT MMK MMM[MMMT MMM[MMR MMR MR[MMMT MMt,�MI DEDICATED SPECIAL WASTE SYSTEM MMR PIS MR MMR MMMT MM S S MMR,_ insMMM mDEDICATED GAS/OIL/SAND SYSTEM MMR MMMT MMR MMM(.MMMT MMMT MMMT-ma MMR MMR MMS NMI 11111(1111111 MMR rrwI[Ahueiadl+*1&Th, IMI S S a MMR MMR MMS a s It S MMMT PIIIII MMS a S DEDICATED GRAY WATER SYSTEM MMR MMM[_AAAI SUN S P MMR ma a MIS M5 MN MI MMR �I19][a:\r: /:�p;4;7gy'(N1xyflh1 It MMR MIN_a:MMR-_NMI SI M.IS la MMR.l MI IS M DISHWASHER NWaaaaNES aaaaaISIMS DRINKING FOUNTAIN MMR_NMI a MMR_a a a a ma a a Ms MMMT atm FOOD DISPOSER us a ua.,111111MM<PIM MMM.NIS.MISS MI a u . .MMR. FLOOR/AREA DRAIN ' MMMT s a MI a MMMT EIS MMMT a MS a a a a . ': INTERCEPTOR INTERN' MMMT MU a Olin.MI ern#M/,aaa MMMT mirm KfTCHEN SINK MIN ION MI AAAI a MMR a a NS NM a s.IS NM. LAVATORY MMRI INK a MMMfMMR MMMT—#MMI MMS NM a MIN M PM I MMI ' ROOF DRAIN ilili MIs MI a a la e a MMR NMI MMMT 1111111 MI IS MM I SHOWER STALL MR KM.MR MMM.a[ a PM NMI a MMMI_a_MS a a SERVICE/MOP SINK I(M M MMR MMR MI MMR MI 111.11 1111111 a PS a MN:,MI -- ------- -- - ---- TOILET a l(E MMMT MMMT S M MMMT Ma a a a a Mg SS IIII.MN nig NM MINI NM.11.Nia NS MMR a MMR WASHINGNMACHINE CONNECTION IMrII a a a a RMM 1MM4IIMAM MRM-a M(Ma IaI!M .AMM MAwII cn URINAL �MMR ralk MMM!MMS E7 JT — MMS MMM!MI MMR--- MMMT MMM!aim nn MMR MMR MMR p/y , alTs RIMA M I MMMT IS MI MMMT a MMMT MS IS a MMMT a MMMT. ' - eQ3RY.i AISEAMNMI MI MMMI moo ma is a pm mRa an mar pm MMMT a A alll PIIN INIII IS Mala a a a a Iaaa I.� - �■IM[NS �I■MI 1t MCMI[_M�MMS�����I 111=1111111.1a11.1-1 Milan MMM[SI s MMMT MMMT MMR MMMI MEI MMR /��uMINII INSURANCE COVERAGE' �,( I '' • —— to i i i insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES RE NO D . IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW DABIUTY INSURANCE POUCY fit • OTHER TYPE OF INDEMNITY D 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 aft of the details end Information I have submitted or entered regarding this application am true and accurate to the best of my know4edge and that all plumbing work and Installations performed under the permit Issued for this application will be In cagp9gnae yith aft Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General taws. /v ,[/.�4Y/ PLUMBER'S NAME I rs.V:n m G!e r1 e !uCENSE# I i&90 ( v SIGNATURE MPR JP© //�� CORPORATIONS a r. PARTNERSHIPD#1 n 111-C1:1# • i COMPANY NAMEWA mcgr.r�-e A+ & it. ,ADDRESS I Il �io P�1 I CITY Urr /. yprov4A �STA1E MI ZIP oa1,773 1 TELT (5ofr)-nw- 4554 I FAX 64-19 o-6-i CELL EMAIL I ' • &/2i ?ivy