HomeMy WebLinkAboutBLDP-23-11614 ,J
L' iv _
FOR PERFORM PLUMBING WORK
n=�=
-�= CITY to.,f`Innp�s'KA Q o�-t` MA DATE `' a1-�C�
+t==1=1=: PERMIT#✓�-7� �- /��/�.
JOBSITE ADDRESS IC 0 N.E.0,--rk4- (ZA,,, .)0> OWNER'S NAME SCy-1-�-
POWNER ADDRESS l00 t-1'c ✓-1 it-}tT(L1..4v v TEL(SO% 3 6-7- `1777AX
TYPE OR OCCUPANCY TYPE COMMERCIAL, EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:yj REPLACEMENT:ek PLANS SUBMITTED: YES❑ NO❑
FIXTURES 7 FLOOR-4 9SM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE ■■■�
DEDICATED SPECIAL WASTE SYSTEM ----
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM ----
DEDICATED GRAY WATER SYSTEM -�--
DEDICATED WATER RECYCLE SYSTEM -�_-
DISHWASHER
DRINKING FOUNTAIN �-L
FOOD DISPOSER �M1
FLOOR/AREA DRAIN S'r� F ���
INTERCEPTOR(INTERIOR) 15 ,ig.
KITCHEN SINK , i _____
LAVATORY
ROOF DRAIN MiltiiiiiiMEN
I I �EPA"ram
SHOWER STALL I _
TOILETSERVIC /MOP SINK •
===
i
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES ■■■�
WATER PIPING -
OTHER MIN
MIN
MIN
INSURANCE COVERAGE:
__-_
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES QIN-1-0 ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND 0
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.
.
r
SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT ❑
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and curate to the be of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in carpi' with all Perti rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. g
PLUMBER'S NAME 1(1 ` . S v`n:�k,.. LICENSE# I S 7g I S GNATURE
MP 2 JP❑ CORPORATION :LI 6a.I PARTNERSHIP❑.# LLC
COMPANY NAME I6-P5 ((wv.�.(`\ j ge Au,•� ��C_ ❑#
ADDRESS E..Oi1A-.� 1,c.),1,..,t_
CITY \c.A.vve✓
STATES ZIP O2-33U TEL 77`(- Z�3 • Z� IY
FAX CELL 77`1-2 tr3- 701 (
Y EMAIL IC`PS IP Ivw\L.