HomeMy WebLinkAboutBLDP-20-004627 MAP ' PARCEC :
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
5-4 Li N.
,;_?i .=_� CITY /•M c)C/ 1 MA .DATE U PERMIT# ` 11)-4) 607
JOBSITE ADDRESS A Fc 5--€n C -' -vi ST^ / i OWNER'S NAME S?G I P 1-1-G- In AV 1 '
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OWNER ADDRESS 61 f TEL 'Z,?")if-3- ti(41,.
TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:R: PLANS SUBMITTED: YES❑ NO►'4,
FIXTURES 7. FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB i_ t 1iimisig'—'—'1
DEDICATED SPECIAL WASTE SYSTEM
CROSS CONNECTION DEVICE � ��
IMF' I
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DEDICATED GAS/OIUSAND SYSTEM _ MI
DEDICATED GREASE SYSTEM _. Y i . P
DEDICATED GRAY WATER SYSTEM [ ( .} ;
DEDICATED WATER RECYCLE SYSTEM m� jl � 1` _-1 1 r—
DISHWASHER illir illi11111.4 _ LilirailtillinliiiiMraiii01. K.
DRINKING FOUNTAIN Ij _._..:' _ I 1
FOOD DISPOSER I I I
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FLOOR/AREA DRAIN - __ i_.,,_ _
KITCHEN SINK INTERCEPTOR(INTERIOR) i . - � 5 _ J
LAVATORY
ROOF DRAIN ,�� 1-. _ t '
SHOWER STALL _ .__. .._ .. I
SERVICE/MOP SINK inurilworionimirmunrompimmirmirmr
TOILET 3 _. _.
URINAL i .1. .. ... I.
A _ .I. ..e., I111 _.._ —
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WASHING MACHINE CONNECTION _._ �� `- ,,,�,,, I i _ ; ,.,,,,,_,_1
WATER HEATER ALL TYPES
A a i i j ,
WATER PIPING Mt jail MC Mil MI _ I,—� �. __1 1 --.-
OTHER MI_ ' , 'i
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INSURANCE COVERAGE: _____ w`� " _ y
I have a current liability insurance policy or its substantial equivalent which meets the requirements of M e . 'S 0 ,,
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELO I
LIABILITY INSURANCE POLICY 2. OTHER TYPE OF INDEMNITY❑ BOND ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage requi d3 V diailierr142-11ftheVI-n.1.
Massachusetts General Laws,and that my signature on this permit application waives this requirement. t:. ;—......._._—„ ., ____j
CHECK ONE ONLY: OWNER ❑ AGENT
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 with all Pertinent provision of the
Massachusetts State Plumbingnbi Code and Chapter 142 of the General Laws. (2
PLUMBER'S NAME I "\ �"� f I CSe 1 LICENSE# ' 1G�c i f 1 1 SIGNATURE
MP ID JP'I CORPORATION❑# P rO P 1PARTNERSHIP❑# . LLC❑# _
COMPANY NAME V -_t53 i j c,i-Q Pf4+1 ADDRESS q f (/j 7-Z L LO ( i ;1--(
CITY lam_`1Gk.c rik CAk i I STATE klu4d ZIP Q Z() 7'3 TEL )- ' l9 Cj/ I
FAX I CELL !EMAIL S k/\ J Qf - /� (, i -34, 0 v- -i - c,
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