Loading...
HomeMy WebLinkAboutBLDP-18-006884 ., MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 1 ii CITY Snu-7 4 A24 -mi,-71 y MA DATE t,l7h,F . PERMIT#/.Adr-/r lvo 0 7 JOBSITE ADDRESS ./0 et4,^Sct_ j OWNER'S NAME; /4y, i cr7�.r'c P OWNER ADDRESS TEL; FAX t. TYPE OR OCCUPANCY TYPE COMMERCIAL© EDUCATIONAL J RESIDENTIAL Y PRINT 'CLEARLY NEW:E RENOVATION:® REPLACEMENT: PLANS SUBMITTED: YES NOG FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 S BATHTUB j _ , , �. � ' CROSS CONNECTION DEVICE _ _ ' , DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/01USAND DEDICATED GREASE SYSTEM STEM j r .- . 4 1 ,IA- i / 1 -1.-- /' CIl iU t J- I►f1G. !B 1. I I , DEDICATED GRAY WATER SYSTEM }' ,i DEDICATED WATER RECYCLE SYSTEM 1 } I ` i I a li DISHWASHER , .., , ' i t . DRINKING FOUNTAIN il - o i � • � as . ;i -_u-. 01_ , FOOD DISPOSER .. rtC .. . 4 r , IhsI . - r ai _ FLOOR 1 AREA DRAIN •- - � INTERCEPTOR(INTERIOR) — -_ •_ _ . - ud I .. - ...gip r , - .I KITCHEN SINK ,� v LAVATORY , i , ROOF DRAIN i i . .. a. SHOWER STALL i i it\ r ' _ - , ,- , . , SERVICE I MOP SINK ' . _ I; TOILET i. W - . 1 . ._ 1- IAa.[1 ' , URINAL > ,1 w _ �' 1, WASHING MACHINE CONNECTION WATER HEATER ALL TYPES , _ ; - ,-- - a WATER PIPING I J i a , OTHER ) 9( rA ' 7 ;, -i i 1 .c INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES,� .i NO _ IF YOU CHECKED YES,PLEASE INDICATE TH PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY .—BOND 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. CHECK ONE ONLY: OWNER G AGENT G 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 corn ' c�y•h all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME'' 13 r t n Ai J, b bA r d _ I LICENSE# ; Il 5'77 t SIGNATURE MP' JP i_i CORPORATION a# _ PARTNERSHIP7# j LLC Li COMPANY NAME:,[ 6 d flwrk 6 I I1$ 1--1-174' ADDRESS f)•_0 . a0,X 4 Z CITY 5. ,-1 „/,,/ , „ -- J STATE _7 3- I ZIP L D a l./ O TEL j S&F JTi- Z. Z Z FAX ° CELL I !EMAIL _ -',e -d O,