HomeMy WebLinkAboutBLDP-16-002400 intiP : P/4RaE4, : c fJ ,l�TO rfu1
-�, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT PERFORM PLUMBING WORK
-ry• cC Y,4 CND uT14 ' AM DATEL 1 o/a-6/16 1PERMr# geo
JOBSITE ADDRESS` 0 14,84, L.A. I OWNER'S NAAE Z e r'r y Lc,CInc,,,c:,e_.. 1
p OWNER ADDRESS I I TELr6o )7(NO-a395'FAX!
TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL Cr
PRINT
L CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:(y2 PLANS SUBt TIED: YES❑ NOD
FIXTURES Z FLOOR—. L &5A1 L 1 1 2 1 3 4 1 5 1 6 7 1 8 J 9 1 10 ,1 11 1 12 1 13 1 14
BATHTUB ,
CROSS COMECTION DEVICE . ,
DEDICATE)SPECIAL WASTE SYSTEM
DEDICATE)GAS/ON/SAND SYSTEM . , ,
DEDICATED(*EASE SYSTEM
DEDICATE)GRAY WATER SYSTEM 1 i .
DEDICATE)WATER RECYCLE SYSTEM ,
DISHWASHER ,
DRINKING FOUNTAIN
FOOD DISPOSER
_FLOOR/AREA DRAM(
INTERCEPTOR QNTEiIOR)
KTTCIEN SN K ,
LAVATORY Jv i I.
ROOF DRAIN V
SHOWER STALL
SERVICE/MOP SINK 4/0
0014
URINAL v.
WAS1 NrG MADE CONNECTIOF! . ► maWATER HEATER ALL TYPES
WATER PANG
I.
I have a txrrrrlt piety keara ce policy Or Its substantial equivalent which meets the requEements of Ma Ch.142. YES&NO 0
IF YOU CIECKED YES.PLEASE!MATE THE TYPE OF COVERAGE BY CHECKING TIE APPROPMATE BOX BRAE
UABIJTY INSURANCE POLICY OTHER TYPE OF NIFaMTY 0 BOND❑ _
OWNER'S it4SURANCE WAIVER:I am aware that the Ncensee does not have the kmu atice coverage required by Chapter 142 of the
Massachusetts General Laws,and that my signature on this permit application 16641 tits requirement.
CHECK ONE ONLY: CANNER 0 AGENT 0
• SIGNATURE OF OWNER OR AGENT
I hereby ceMafy that al of the details and Information I have subailtad or mimed ruing this application are true and accurate b the.- of wry Imowledge
and that all plumbing work and imlallatons performed under the permit issued far this application we be In cart/ rence W - .,of the
Massachusetts Slate Plumbing Code and Chapter 142 of the General taws. - -_ %�
/
PLUMBER'S NAME I K'w n 1110Brje. I UCBJSE# 1 16aO r - -i- TURF
kV El .13❑ CORPORATIONEI PART ❑#1 - iU.0 pit '
MANY NAAE ,:n Al r:d o P ADDRESS I tl h, Peed I
CITY W. YGrMtav'4-4 ISTATE wit BP 02.673 TE (5of) - 4654, I
FAX .Goer" o*61 4 CELL EMAN.