HomeMy WebLinkAboutBLDP-20-002270 mAP: l31912 c et
SJ, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
__' CITY Yl f-t YINA-1-i11 MA DATE 01a:/ 1/I'? PERMIT##40/2- -06'2 x'
JOBSITE ADDRESS ,`2)l '5ir�C 1,11: II NA ( OWNERS NAME c 1C L_ r l ti t I I Q e_ I
-OWNER ADDRESS '� �rift � I n I I LIT(Ye- I TEL 'FAX
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TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
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L CLEARLY NEW4 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7 FLOOR-i BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
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DEDICATED GRAY WATER SYSTEM _ _,aniimilmigi;Iam,Im Imo low;i I l.=.l I ..mit
DEDICATED WATER RECYCLE SYSTEM I__1; INN pm im.rw am...;imilimilim
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DISHWASHER
DRINKING FOUNTAIN _ . _ nomMenannilmOS� , 1 -
FOOD DISPOSER � �����i�� � -
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FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
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KITCHEN SINK
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ROOF DRAIN - - - - --11 ,1 In -
SHOWER STALL RRRRURRRRRRRU
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SERVICE lMOP SINK imam
TOILET I
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�� — .—~--` INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES4 NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LABILITY INSURANCE POLICY, OTHER TYPE OF INDEMNITY❑ BOND❑
•
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 ❑ AGENT ❑
. SIGNATURE OF OWNER OR AGENT -
I hereby certify that 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 been compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. . �
-PLUMBER'S NAME PP:k{ ,:►o`` LICENSE# :26"?7 9i/. .
SIGNATURE
MP6 JP Li CORPORATION❑# ' 'PARTNERSHIP❑# LLC❑#
COMPANY NAME P?A
.f i ,1G> 1 ADDRESS (e r C 1IC`,(c 9_ Uia
CITY Wry--y-- Y t T1( 0 U tikk I STATE It A Iett- ZIP !')21,7 TEL T L r.1L -07 3^I- .S c"(. ) I
FAX (CELL 1 EMAIL
ROUGH PLUMBING INSPECTION NOTES JELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT# PG-
PLAN REVIEW NOTES /F /1)7 Q
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