HomeMy WebLinkAboutBldp-16-001425 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING,,� „„ WOR
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A;" mo ., MA DATE 9/i//s _ +PERMIT# 660/9 /6-�x"
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JOBSITE ADDRESS 1..374 4_3 , 0n,-I- i A OWNER'S NAME Ir, I prbick
P OWNER ADDRESS 13-.7 (Ogel(ellc, I TEL ,FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL
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CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:n PLANS SUBMITTED: YES❑ NI '
FIXTURES Z FLOOR--* BSM 1 2 3 4 5 6 7 I 8 9 10 11 12 13 t
BATHTUB , , _ _ r
CROSS CONNECTION DEVICE _ L , _ i
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOILISAND SYSTEM 1l +, - 10- -- .,.
DEDICATED GREASE SYSTEM �.
DEDICATED GRAY WATER SYSTEM ! - ---' _ i mil mini
• DEDICATED WATER RECYCLE SYSTEM - -. _-'
DISHWASHER
DRINKING FOUNTAIN , I 10110,ill� '
FOOD DISPOSER — ,OW ;
• FLOOR I AREA DRAIN IIIMI
INTERCEPTOR(INTERIOR) _' ,
KITCHEN SINK INN MUM.01111=111 ma
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LAVATORY �l ''�I� I.
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SHOWER STALL 11 II I, .��� 11111111�no, OM Mt
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ROOF DRAIN ...1111.I.....1.411111111.
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TOILET 111111111.11111111111 MINIMINI MINIAMI NMI iliiim 10.1
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WASHING MACHINE CONNECTION EMEN1111111.1.1011111111111111011111mum
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WATER HEATER ALL TYPESw ow PIO Mini
WATER PIPING
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INSURANCE COVERAGE: a
I have a current liability insurance policy or its substantial equivalent which meets the requirements of Mi Ch.142. YES❑ NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BE ,
LIABILITY INSURANCE POLICY n OTHER TYPE OF INDEMNITY ® BOND
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OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverag; ,:` 3 ,jtj rit ,'f th
Massachusetts General Laws,and that my signature on this permit application waives this requirem ,,`- •
CIS „,,,,(1.. • ;` '
SIGNATURE OF OWNER OR AGENT F .., ,r
i I hereby certify that all of the details and information I have submitted or entered regarding this- ' . rate to the bes - my knowledge,
and that all plumbing work and installations performed under the permit issued for this appllc , , fi" x ` • tall Pertine. •rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �'>',' _ '.' q
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PLUMBERS NAME�,-r�s �q,�,�%.5 " . . �. . ._ 'LICENSE# �,,��
MP JP❑ CORPORATION(# d �`- #
'� COMPANY NAME S,eJ� I ADD • '1'-
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CITY 'Der,-- STATE Y) j a .„
FAX L CELL EMAIL i µrc
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