HomeMy WebLinkAboutBLDP-15-004708 /\
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L MASSACHUSETTS UINNFORM APPLICATION FOR A PERMIT TO PERFORM
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(YNNERS NAMEt-----11L.Z0.5 &'4.. i
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JOBSITE ADDRESS 1 , , 0 / V5 r _
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EDUCATIONAL LJ RESIDENTIAL _,Ci7_,4
TYPE OR OCCUPANCY TYPE COMMERCIAL , ,.
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CLEARLY NEW: •-__, RENOVATION:i,- ,I REPLACEMENT:I L., PLANS SUBMITTED: YES i,.":-../
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FIXTURES 1 FLOOR-, BSM 1 2
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CROSS CONNECTION DEVICE — - mm a al mp =DEDICATED SPECIAL WASTE SYSTEM lummim s_nn
DEDICATED GASIOIUSAND SYSTEM smt2 _ —.,=DDICATED GREASE SYSTEM i MoEElIlWTimal
DEDICATED GRAY WATER SYSTEM iiiiis =-M 0111i1P111
DEDICATED WATER RECYCLE SYSTEM 1iii'ii usm
DISHWASHER 1.
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DNKING FOUNTAIN oirniFOOD DISPOSER ji g a n
FLOOR/AREA DRAIN 4sNg .as =
INTERCEPTOR(INTERIOR) S WN S M 101all
KITCHEN SINK NN 1111117LVATORY W i ==r a = 1
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ROOF DRAIN
SHOWER STALL
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WASHING MACHINE CONNECTION ' l.Mi1f_Elm 1111101 MN NIS NMI 1111111111111111111 IMO gni rims Mal IMIP IMP IMP 111.1=
WATER HEATER ALL TYPES --lilt". 'lel WI NIP 1111P
WATER( PItei 07.°2110.b Age. i ......,...............,,,,,imiqpi an iz 70 sunin.1;071 lane
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-- INSURANCE COVERAGE:
I have a current Sabath,Maumee policy or its substantial equivalent which meets the requirements of VOL Ch.142. YES L-e.40. IL".j
IF YOU CHECKED YES,PLEASE INDICATE TyPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
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LIABILITY INSURANCE POUCY, .,, OTHER TYPE OF INDEMNITY 1_, BONO L..„
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 14201 the
Massachusetts General Laws,and that my signature on this permit appWcalios mg this tequirament
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CHECK ONE ONLY: OWNER I___J AGENT L I
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 Imo wledde
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.
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PLUMBER' NAME i DTFQ/E Of Le.c?-?.rcil- ., ._ ! [CENSE#t/ 5 i(26, ;
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CORPORATION 'L-# 7..7 ly PARTNERSHIPC-1,fil, 1 LILL'itil , ..t
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COMPANY NAME! STfcir 16 ItZoS 1:-/)- 1- SOA.SIDDRESS! 7/ ri)/r Ce 61-t-r LA S (
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ZIP
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CITY!! CM./ /-0 - ,STATE 1.444
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FAX BC?).0,48 i CELL S37-6^091 _ _ _ ._.,_ .. ....