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HomeMy WebLinkAboutBLDP-20-002335 $:, MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK �- CRY C 'A (� ---1 MA DATE it P,..� PERMIT#�!D/�`4DbO I3 t � � r meanADDRESS ��5 AI:LvrJ P n '.�'�, 1 OWNER'S NAME &,I L:.r,rjc Co r 1 P OWNER ADDRESS I TELI7.74 al 2 -117 1 jFAX 1 TYPE OR OCCUPANCY TYPE COMMERCIAL© EDUCATIONAL ® RESIDENTIAL' PRINT CLEARLY NEW:® RENOVATION:® REPLACEMENT:kf PLANS SUBMITTED: YES® NOD FIXTURES 1 FLOOR-, BSM _ 1 l 2 3 4 5 B 7 8 9 10 12 13 14 BATHTUB 1 1 1 1 , 1 11 1- _. i i , �. , �1 , V✓ i!. A - Y �i. .mil W•....M•••im iii/I04aYT—W il/ CROSS CONNECTION DEVICE W ; _ _ DEDICATED SPECIAL WASTE SYSTEM y DEDICATED GASJOIL/SAND SYSTEM a - . 4 _ T��— DEDICATED GREASE SYSTEM i, -I" .-- DEDICATED GRAY WATER SYSTEM 9 a R DEDICATE)WATER RECYCLE SYSTEM '-- -_ DISHWASHER , F g DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN } INTERCEPTOR(INTERIOR) I KITCHEN SINK c __ t.- i LAVATORY -ROOF DRAIN e F► 1 SHOWER STALL SERVICE/MOP SINK 3 _ .,t _.- - _ a } TOILET r URINAL .. __3 s D - WASHING MACHINE CONNECTION a _ WATER HEATER ALL TYPES tf WATER PIPING __ - �, ___ ..__? . ._ . _ _1 t OTHER - _. - -- - -- -._^ it R..-._Tl y -----Y_"-i _...... _ - - -- - - • INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES"NO El IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY L! OTHER TYPE OF INDEMNITY® BOND OWNER'S INSURANCE WAVER: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 0 AGENT • SIGNATURE OF OWNER OR AGENT I hereby certify that all of the detafs and kduunalon 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 mrreuPn'e with all y n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. J c1 e PLUMBER'S NAME Ke.o.p.-litC-'8r I LICENSE# I (aO !_ .:1- `SIGNATURE MPf JP© CORPORATION # 8 'PARTNERSHIP®# . - LLC0# _ ., - 1 COMPAYNAMEJT (ADDRESS L LI ! ,O a ..._7„.. J CITY W. `/r r nr a r,4A - 1 STATE (y)A ZIP D o2 6,-7 3 TEL (66 0 g)-7 ' E D FAX 4o4-7 In-u1Sc1 CELL(.5_603(A.37 EMAIL _ ._.. _ BIJILDif1G DEPARTNl-NT N \ Z 1V