HomeMy WebLinkAboutBLDP-19-004047 MAP: PA91e c e t
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
� 1i "1 !( PERMIT# /9 nr l r-t'el/0 97
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JOBSFFE ADDRESS 13 6.9 S‘a, 1,0., At� 1 OWNER'S NAME >ail i Q./1 Cad t I1 n 1
OWNER ADDRESS [34-0 SII h-o' 'dam- I TEL 411(- 36 -20201FAX I
P TYPE OR OCCUPANCY TYPE COMMERCIAL ElEDUCATIONAL D RESIDENTIAL% ,
PRINT PLANS SUBMITTED: YES❑ NO❑
CLEARLY NEW:ID RENOVATION: REPLACEMENT:El
FIXTURES 7. FLOOR-' BSM 1 I 2 3 4 5 6 7 I 8 9 10 11 12 13 14
BATHTUB 1 A — l <' J
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CROSS CONNECTION DEVICE '
DEDICATED SPECIAL WASTE SYSTEM - � ,'—'
DEDICATED GAS/OIUSAND SYSTEM LINIIIIIIIIMINIFIMMIMMIIMIllerrellr , -
3
ED GREASE SYSTEM a1
DEDICATE
D
DEDICATED GRAY WATER SYSTEM Nal
I ' MIAMINI NM M -
DEDICATED WATER RECYCLE SYSTEM 'V
DISHWASHER WE.
DRINKING FOUNTAIN I '.M
FOOD DISPOSER ��1
IltI • 111. — 1111.1. = ,
FLOOR/AREA DRAIN at
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INTERCEPTOR(INTERIOR) llill t11
O___.llir pIa imare loffla_'ia
a.Inrm,
INTERCE SINK - :
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LAVATORY nt -
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK I - ' air 1 (;
TOILET �a� -
URINAL al! „ 1
WASHING MACHINE CONNECTION W i__ • _.._ . __
WATER HEATER ALL TYPES NM W�wii ± i -- -
WATER PIPING
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OTHER Io ► '[/ IA m � ._.— .i— a
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ILLM,10-011_111TM.— ---jill11 PIM _:—
• INSURANCE COVERAGE: .,
I have a current liability insurance policy or its substantial equivalent which meets the.A•equirements of MGL Ch.142. YES�O []
IF YOU CHECKED YES,PLEASE INDICATE TH E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY OTHER TYPE OF INDEMNITY ® BOND 0
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 LI
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 coMpliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ( 1.
PLUMBER'S NAME IA 11 It.�,i1' C 0 I ,11 I LICENSE# 3/ SSJ SIGNATURE
MP® JP NY CORPORATION0# PARTNERSHIP®# LLCC]# I
COMPANY NAME A ►\`;-a U I,A !ADDRESS 16, t;Li o4t..1,r 1 ciku.lei" !
CITY 'SG vtitiA. tililihi,;;,;ik ISTATE /'Vi A I ZIP C t-L TEL
I TEL 1
FAX CELL {EMAIL A(ISCh fk,ttv ll`L iLsu, ( (;rl ? �A�i
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ir377 CPART .4
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE 9NLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT
ifV/bl. I all' FEE: $ PERMIT#
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PLAN REVIEW NOTES "C
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450.„0
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