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HomeMy WebLinkAboutBLDP-20-002712 sz, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK =9: CITY C _ VA CITY U ()� •J-1� ^� MA DATE 1 L I g PERMIT#f)�-�°�-t"z�!/� JOBSITE ADDRESS l 11$ e re.nie(ry L. I . I OWNER'S NAME 4id r•e.0. 14C6P_e 1 POWNER ADDRESS - 1z ,^�.�" '3-75.5 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ElEDU ATI1 L. , 9 -,'= Al-to PRINT �/ CLEARLY NEW:D RENOVATION:® REPLACEMENT:I " NOV 0 7 2Q193LA S 'UBMITTED: YES D NO© FIXTURES 1 FLOOR-, BSM 1 2 3 4 _-S. 7 8- 1 9 10 11 12 13 14 iLu ` 07 FAPrT 'Eta e BATHTUB r-_ CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM ___ DEDICATED GREASE SYSTEM m m aloft -7 -illinliff DEDICATED GRAYATC TEM SYSTEM 11111111111111111111nUngignan DEDICATED WATER RECYCLE SYSTEM _DISHWASHER innini DRINKING FOUNTAINnuns FOOD DISPOSER FLOOR/AREA DRAIN - ^— -RRR ..R .••U INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY -ROOF DRAIN SHOWER STALL I SERVICE/MOP SINK TOILET WASHING MACHINE CONNECTION am,am WATER HEATER ALL TYPES WATER PIPING OTHER . _ . _ _ , li - III _ . INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY E OTHER TYPE OF INDEMNITY ® BOND Ej 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 El 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 com and that all plumbing work and installations performed under the permit issued for this application will be in n Wirth alE �� r0 ' ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME KeA.) c .hi rJ.3r: O 1 LICENSE# I (.O J SIGNATURE MPE' JPQ CORPORATION#(378(aVC, IPARTNERSHIP®# • - LLC®# _ - - 1 COMPANY NAME ( CB,;j_e Ezt _ ,._1 ADDRESS /j (iO Jr P�•i ,_ J CITY W. \/6,,-,y,0%,4A STATE (Y)A I ZIP D a 6-7 7 TEL 16 O E -77 1 �'� 45S1 FAX 5of-1''i0-0fx1 CELL)g9930.37AI EMAIL , ._ _ten G p, n b ® co enepts4 1 's'-4 . I L R h 8zD