HomeMy WebLinkAboutBLDP-16-000373 F - - - - \/ ,,
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SZ., MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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CITY ` v 0711 y�d24?10i. 1_ MA DATE 2/2./)/i S'' 1 PERMIT# 0P^/6—000`37 9
JOBSITE ADDRESS Z9. ../?4144;, )2 _ .t OWNER'S NAMEf 6 s fit, ?441i/AA .1/II i
POWNER ADDRESS TEL !FAX s
TYPE OR OCCUPANCY TYPE COMMERCIAL ED EDUCATIONAL 0 RESIDENTIAL[—
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CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:Lg PLANS SUBMITTED: YES 0 NO M
FIXTURES 7 FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB j 1 (.
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM j 1 t
DEDICATED GAS/OIL/SAND SYSTEM
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RP'' SI
DEDICATED GREASE SYSTEM --
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DEDICATED GRAY WATER SYSTEM ? I I I! �I ', MIIIIIIPI '
DEDICATED WATER RECYCLE SYSTEM ,
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN —
INTERCEPTOR(INTERIOR) ,
KITCHEN SINK
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LAVATORY 1 f
N 1 P.. "r V ...... / 110 i .0..TIM i . V/Ill 41 all _'.Ir "f 4 ./4' _V..1 '1 7
ROOF DRAIN
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SHOWER STALL i ' , 4 , .' .,,.-A _,., - _
.. _, ' � w_ary ,.GPM r _ rrr _�-� 1 M �— r
SERVICE/MOP SINK
TOILET
URINAL IIIe; 11111111_11111111WASHING MACHINE CONNECTION on on a INN NMI , NM nil NIS WIN• ;. ,
WATER HEATER ALL TYPES
WATER PIPING
OTHER C _
MIN MIN 111MR NMI NIB III NMI INN MIS NIB NM NM INN NE
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liabilitypolicyl� alent which ..
INSURANCE-COVERAGE:
I have a current!!lit!' insurance or its substantial meets the requirements of MGL Ch.142. YES Ej<10 0 r
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
JUL, (_) 2015 •
LIABILITY INSURANCE POLICY[,-2 . OTHER TYPE OF INDEMNITY 0 BOND 0 -4,;lc-z (6' 4l
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 0 AGENT 0
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 all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME I RA2,,4A/ iiiii,c_1—ci I LICENSE# //17 7 SIGNATURE
MP ay. JP El CORPORATION L PARTNERSHIPD#� LLC 0# I
COMPANY NAME JC,4roc _eaf/m 1-14, ea At I ADDRESS I ?b.,67o,X y ZS I
CITY I S', 0Ad/,4/1/ _ J STATE /?Q ZIP I co 2 6 I0 ITEL '
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FAX , CELL 1 1 EMAIL
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