HomeMy WebLinkAboutBLDP-20-002683 I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
70 CITY t, Q.,4111�Q 1! h 1 MA DATE I PERMIT# I �/ IO-�Id v�6S.'
JOBSITE ADDRESS e4,44 LA/L. I OWNER'S NAME,
? OWNER ADDRESS »v.._. ......_: TElt w.._ _ A,._..-JFAX[
TYPE OR OCCUPANCY TYPE COMMERCIAL Li EDUCATIONAL Li RESIDENTIAL'
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CLEARLY NEW: ' f RENOVATION:1 REPLACEMENT:'x' PLANS SUBMITTED: YES I NO
FIXTURES 1 FLOOR-V BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB w.._ 1 ;_ ..- i 1 __ f s, 1 ;
CROSS CONNECTION DEVICE --1' — INIKINCISO ', . ' �� _ __ j
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIUSAND SYSTEM } i ;t11 ' 3�'� IS -"
_DEDICATED GREASE SYSTEM i r m`M OPP NMI*
DEDICATED GRAY WATER SYSTEM s I 1 :".;7.-...""'
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DEDICATED WATER RECYCLE SYSTEM r l ,j .' ; .
DISHWASHER ( � „ I i "
DRINKING FOUNTAIN
FOOD DISPOSER - t VW ; 1 Mai f IMPI ink
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FLOOR/AREA DRAIN i ! ' _ }
INTERCEPTOR(INTERIOR _' , t
KITCHEN SINK I11> �
LAVATORY I } . i
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ROOF DRAIN I
SHOWER STALL NM r 1 NMI Mai
SERVICE/MOP SINK PM _',. . NO I 1 �'" ; fism nu
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TOILET NMI M ION aliii We NW MN N M, NM NMI
URINAL IMP Ms iiim MI opm I IE NMI :
WASHING MACHINE CONNECTION an a op ow m isli optima mom
WATER HEATER ALL TYPES .. Mk Mitilnili ingi`MN 11111111100 NO' IN MOM MON
WATER PIPING .;IWO Miii t I M" ..r
OTHER ?
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INSURANCE COVERAGE: t?1 66
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES,; NO I 1
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE 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 ' AGENT l_,
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 egili tprovislon of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws c- }
PLUMBER'S NAME in o-3'i j INA C, 1,(J ?LICENSE#"155 et RE
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MP'x; JP 1. CORPORATION 1 I#1 ., . 'PARTNERSHIP I I#1.,, I LLC i J#1
COMPANY NAM ADDRESS,
cLla. C-dtL�,a_sko_p4k,vival lz 1i Gael, .'Z�J.tali0,,.A, J:CL j
CITY STATE imp( i ZIP TEL
FAX ! i CELLI 1 EMAILirk YIC , 64, I
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