HomeMy WebLinkAboutBLDP-15-000869 =\ MASSACHUSE I Is UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUmt_ING WORK
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0 : JOESITEADDRESS /7 Steil) L OWNERS NAME so/ t'f- i
pOWNER ADDRESS fl/, 'Aurde14'e 'R 1, TEL 30%641-2?2EAX
TYPE OR OCCUP.ANCYTYPE c+ hcS f�At'uffd 0 mid 817 EDUCATIONAL 0 P.ESIDENI"IAL,
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CLEARLY NEW:5C REJ4OVATION:0 REPLACEMENT:0 PLANS SUSM If i ED: YES 0 NO ❑
FIXTURES 2 FLOOR BSI Iv-I I 1 12 13 14 15 16 17 16 9 11 12 13 1410
BATHTUB I I I I I I I I
CROSS CONNECTION DEVICE I I I I I I I I I
DEDICATED SPECIAL WASTE SYS
DEDICATED GAS/OIUSANDSYS I I I I I I I
DEDICATED GREASE SYS I I I I I I • I I
DEDICATD GRAY WATER SYS I I I I I I I I I
DEDICATED WATER RECYCLE SYS I I I I I I I I
DRINKING FOUNTAIN I I I I I I I I I
DISHWASHER I I I I I I I I I
FOOD DISPOSER I I I I I I I I I
FLOOR IAREA DRAIN I I I I I I I I I
INTERCrrIUR(INTEPJOR) I I I I I I I I -
KITCHEN SINK I I . I I I I I I I
LAVATORY--. I IJQ I - I I .I I I
I ROOF DRAIN- I I I - I I I I I I
SHOWERS TALL I I5CI
SERVICE/MOP SINK • I I I I I I I I I
TOILE I e•••I. I I I 1 - I I
URINAL
I WASHING MACHINE CONNECTION I I I I I I I I I
WATER HE4TE'i,AU_TYPES I I I I I I I I I I
WATc"Ri PIPING I - II I I I I 1 1 I
OTHER - I I I I I I___ __ _11 1
I I I I I I I I I I I
I I I I I I I I ]
• • INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which,meets the requiremends of MGL Ch.1 L YesKNo 0
IF YOU CHECKED YES,PLEASE INDICATE EE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICYX OTHER neE OF INDEMNITY 0 BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of fl
Massachusetts 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
• certify that all of the details and information 1 have submit ed (or entered) regard ng his application Ora true and accurate fn t
Q of my Knowledge and that all plumbing work Int"
perionned under the permit issued for Phis application will be
W _ . pliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of Gen
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:l3RNA1JE vc�hh �I�inP1. SIGNATURE p
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111 Q cit .. # a20 7o MP❑ JP2 CORPORATION 0#
PAR NERSHIP ❑# uc
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ti. a -ANY NATE SIGNATURE
riu- �j,�-,Lt "..1 ADDRESS: 76 Scv Aettoi ,rC�/��
i �-ydrmo t 7 / STATE IW ZIP S6_ &HAIL J+C/w.un&y 'lorni1 100 r-iig L<q,,
__ TEL w-22l-S2 7 CELL foo-22I-f7s-7 FAX \/ "
renin[TION NOTES
ROUGH PLUMBING TNSPITCTCON NOTES THIS PAGE FOR iNSPTCCTOR UST+ONLY
/?ly,L /2_G of- fAL//y Yes No
A. Cs O, s-iv-B,s 1„ 0 0
FEE: $ PERMIT 1f
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