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HomeMy WebLinkAboutBldp-20-002372 `'_Y AVP : P/4ReEG : MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK - --,,: j- CITY 74 e m 0 UT1. - ( MA DATE 10/9.Ali 1 q . 1 PERMIT#& .eg7R JOBSITE ADDRESS , 9i L Ie,yie >, DI:. 1 OWNER'S NAME Sever 61 r-tat I�Li. , i P OWNER ADDRESS 1 TELt334 a35-34 0 IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW:© RENOVATION:® REPLACEMENT:U PLANS SUBMITTED: YES® NO❑ FIXTURES Z FLOOR-, I BSM 1 2 3 j 4 J 5 1 Y6 7 ._ 8 9 110 11 12 j 13 j 14 BATHTUB CROSS CONNECTION DEVICE r .y_ DEDICATED SPECIAL WASTE SYSTEM _}; _, DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM __ _._ DEDICATED GRAY WATER SYSTEM , . :o R _ DEDICATED WATER RECYCLE SYSTEM DISHWASHER x - Z _ DRINKING FOUNTAIN FOOD DISPOSER u FLOOR/AREA DRAIN a_ , I. _ INTERCEPTOR(INTERIOR) KITCHEN SINK , V N. _ LAVATORY ROOF DRAIN LL -ti SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES CD WATER PIPING OTHER .. . . ._.__._. III _ __ __ .. _ imillang :IR MEE 111 MR . INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142.._ NO ri,—d_._y ,f IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW i ... / LIABILITY INSURANCE POLICY Id - OTHER TYPE OF INDEMNITY El ®BOND � �-;,.. i iN 1 h) OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by I hapter of the t Massachusetts General Laws,and that mysignature on thispermit a ication waives this requirement i .._ ___._. ..-_w.-. .._..._.� 9 PPr � ,t:Fi��i�E� u�F�A Pr�,��r�r CHECK ONE ONLY: AGIEta • 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 be in mrr-Puorim 4 h all '-% ro ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Alki' PLUMBER'S NAME K.A.)'r in 017C'Q e- 1 LICENSE# t l-‘d.© ' SIGNATURE MP 1' JP® t CORPORATION�#�kGh G PARTNERSHIP®#1 /_� 1 LLC®# COMPANY NAME t CILl e_..P�}L - ( ..J ADDRESS 11 ilia P ,/ - . 1 CITY' W. ‘iic,,r-ryt o-. 4A $STATE MA ZIP l Da6`?3 I TELL (6 0E)-7-7i- 465 FAX t6of'7'i o-ts f 1 CELLtry, 30.37 EMAIL 16ill (``)ID_m b..to co n2 il%t5'} ., n P,-) _ 1 n `Z p