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HomeMy WebLinkAboutBLDP-20-002960 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK -ky CITY —— Y,Y I2 (y) o L)Th MA DATE PERMIT# p aP`°zi-Od,1 g6j JOBSITE ADDRESS 49-7 W_,evS ,,r 6-rt'y ().oI_ ] OWNER'S NAME ppJef' !Y/nU 14fin 1 POWNER ADDRESS - - __ TEL__ _ TELI/5•ob)?37_ io85 (FAX TYPE OR OCCUPANCY TYPE COMMERCIAL_j EDUCATIONAL ��RESIDENTIALI ' PRINT CLEARLY NEW:Li RENOVATION: REPLACEMENT:Li PLANS SUBMITTED: YES© NOQ FIXTURES 7 FLOOR BSM 1 2 I 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 11_1111.ral IIIIIIIIIIIIUIIIIIIIIIMIIIIIIIIi `1 IM.1111111111,1111111 CROSS CONNECTION DEVICE _L ,____.,�( . __ I Il l DEDICATED SPECIAL WASTE SYSTEM _ _ __ is ? _ Y. r. ,- ii DEDICATED GASIOIUSAND SYSTEM III, T i - f ! �ii I DEDICATED GREASE SYSTEM IMILOSI _ _ ____I-___;_ DEDICATED GRAY WATER SYSTEM i__ I __ Mi,' y 1 1 II DEDICATED WATER RECYCLE SYSTEM IC ,- I _ I___ , 5i amanwWIDISHWASHER M1���i .._ I EM 1111111111111 DRINKING FOUNTAIN 7— M +,I____ I T_ M._ _IMMTMERIEBWi FOOD DISPOSER FLOOR/AREA DRAIN Ra*RiRRRRR11•) __ INTERCEPTOR INTERIOR _ ,' ___ _ _ Tz IME li M KITCHEN SINK _ . r4PJ aii LAVATORY ! 141Ii l dI ._ ROOF DRAIN I , I IuI .rmSHOWER STALL _ .. ._.- I _ M( I I SERVICE I MOP SINK 'i " ' TOILET W, ;MI , URINAL _rl' 111111111112 i WASHING MACHINE CONNECTION NER' 'i I� ' WATER HEATER ALL TYPES ,�nij ' i WATER PIPING _ ! E lijl OTHERlit ! a ? ill i' i' ( i___________ _.. __..,.,.__.___„. ___ ___.___wingiskintiggsing__ _ rumiimprigg, miumtm INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES IA/NO Q IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ''( OTHER TYPE OF INDEMNITY ® BOND ® NO 2 n Mg 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. C+'+/25-V '1415 CHECK ONE ONLY: OWNER 0 AGENT El • 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 mrcelk,nce with all ent provjsion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. arf ' PLUMBER'S NAME j e ..r J', _r'. C. J A _ 1 LICENSE# )liviCIO 1 SIGNATURE MP I JP 0 CORPORATION Lt#o_ZW t ._PARTNERSHIP 0# . _ ..(LLC 1..J# COMPANY NAME,d.'tl,,..Afid C. .,,:LL..C_:}_ ___. ..j ADDRESS ___la,__.L/lg .. .. /_�.__ ..____-__.. ._� ...� J CITY PI `/ .c.fl, ',,-}A_.. ..._..-3 STATE my ( ZIP d 1,� 3 TEL (6 0 E)-7-7F`_4 "4 FAX 5Ct Iq0-!i1L'‘_ CELL 5D1)30.37 EMAIL e(y, /+f ''i..A_ co . .'- , 02ft O 3 1