HomeMy WebLinkAboutBLDP-20-001681 -%%er MAP:
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MASSACHUSETTS UNIFORM APPLICATION FOR A PER T TO 'ERFORM PLUMBING WORK
/ .�.� MA .DATE`rri F PERMIT# /1/ZA/I I G
"= " CITY ���L✓ tI
-- —'` - /�—�—Q� OWNER'S NAME k,[ [ ,. ' UZ4 L E 4
JOBSITEADDRESS � �'�� 1-"�'� TEL FAX
pOWNER. ADDRESS RESIDENTIAL�- '
TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONALPLANS SUBMITTED: YES❑ NOW
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: 10 12 ® 14
r-,� -W
4 5 6 7
FIXTURES 7 FLOOR ® I , W �.[ M '.
CROSS CONNECTION DEVICE OA _! O O 1 10m__1..
DEDICATED SPECIAL WASTE SYSTEM SO 001 ' ; ,0 _'1 0.,-
DEDICATED GREASESAND SYSTEM illy' 0 1 , '1;r 1�'OM `
DEDICATED GREASE SYSTEM TW
MI
DEDICATED GRAY WATER SYSTEMS ---[ w-I�[ly��l �, � �
iwornimimi
DEDICATED WATER RECYCLE SYSTEM101111 XIS i��IAE;
DISHWASHER 1*� 01[•''/�u7Gr ,� �0= �[W;�
0.110.1
DRINKING FOUNTAIN �`�;L ..�i i.WR �[;,)l ,i III-- Il I���
FOOD DISPOSER U V�.ON- wM
FLOORIAREADRAIN1111110.11 —,i , ;ice"���m ow 1 _.—
11.10.1
INTERCEPTOR(INTERIOR) i�' i ,, ma' _t
it am• IMP „Pl �kI { is j
IIII
LAVATORY �; �� �'
ROOF DRAIN _IrM1-0i1l(' 1.111 �Will � ';il
SHOWER STALL r—i � I ! '; '- Will,
SERVICE/MOP SINK
` �
TOILET W �; I i
WI
WASHING MACHINE CONNECTION '+W1W— ', '_� Il;I W� ' '
WATER HEATER ALL TYPES •M11111W1110000 i ,
_, ;��I—�_
110-011
OTHER .•, ��l
L ,. INSURANCE COVERAGE:
policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES® NO ❑
I have a current liabili insurance
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY a
OTHER TYPE OF INDEMNITY 0 BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee ve the
insurancen this coverage required
t uired by Chapter 142 of the
Massachusetts General Laws,and that my signature on thispermit
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT •
are true and accurate to the best of my knowledge
I hereby tha certifyll that ll of the details and information I have submitted oit entereddf regarding g tcis application
and that all plumbing work and installations perform142 o under the
permit for this application will be in
compliance with^t Pertinent provision of the
Massachusetts State Plumbing Code any ChapterBSI—GNATURE
PLUMBER'S NAME hk an�� ����KM,M LICENSE#
MP® JPa
CORPORATION#I (-0 PARTNERSHIP❑# LLC❑#
COMPANY NAME ,gn�� ADDRESS i' TEL �� �
CITY S iwall
E= 3:1kT GEtZIP "Y7 ((( 73 I
IL taw _ � a
FAX CELL ' - I, ., )
U
ROUGH PLUMBING INSPECTION NOTES
BELOW FOR OFFICE USE ONLY
FINAL INSPECTION NOTES
THIS APPLICATION SERVES AS THE PERMIT Yes No
0
FEE: $ PERMIT#
C� AC G 2 77z
PLAN REVIEW NOTES
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