HomeMy WebLinkAboutBLDP-15-001963 /62—a ) co41l /- .
-e\ MASSACHUSETTS UNIFORM APPLICATIO fOR A PERMIT TO PERFORM PLUMBING WORK
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r CITY 'br ft 74,-....e.. MA DATE /0/ti /i PERMIT# f��16--00 %j
JOBSITE ADDRESS II t 1.4.,:;;1.4.,:;; .Sn^7e dPrD OWNER'S NAME Pr5d /act /on r
OWNER ADDRESS V:21 k/.;, S s,-,o Rri TEL FAX
`Q\ TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 • RESIDENTIAL gi
PRINT
CLEARLY NEW:❑ RENOVATION:VI REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
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FIXTURES 7 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 1 4,
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM .
DISHWASHER
DRINKING-FOUNTAIN - -. - .. ..
. ' FOOD DISPOSER
,1 FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) _ ,
KITCHEN SINK
LAVATORY y 3
ROOF DRAIN
SHOWER STALL 2.
SERVICE/MOP SINK
TOILET I 2,
URINAL
WASHING MACHINE CONNECTION
-Vim ER HET AILST' StD / , .
1/4ATEWP(PI14L fi--+ 0/410 g
OTF EYInnb 7— 3/46e/(1 ` e
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/V/�y�) INSURANCE COVERAGE:
1 have aiurtencllaoutty insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO EY
:.- IF-YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATEBOX BELOW
LIABIUTY INSURANCE POUCY 0 OTHER TYPE OF INDEMNITY 0 BOND 0
e rt ER'S INSURANCE WAIVER: ;am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
as .chusetts Gen: al Laws,a d that my signature on this permit application waives this requirement /�
. 1 %iLAS CHECK ONE ONLY: OWNER Er AGENT 0
tillnR. ..• .- e e NCR OR AGENT
I hereby certify 'at all of the details and Information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit Issued for this application will be in compliance wl all Pertinent provision of the -
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME /3.--Ari fey iohanc SC-7T LICENSE# 306 n SIG ATURE
MP❑ JP ir CORPORATION❑# PARTNERSHIP❑# LLC❑#
- COMPANY NAME Ey-,cP tien c r R f!u ..6-15 ADDRESS /0 '? /44.7,4,7 Sr
CITY .5"..4.--in, o i% Aft' STATE In ZIP Q? x,75 TEL c0 - /ZT- Lk 47/
FAX _ CELL Sk n, t EMAIL
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