HomeMy WebLinkAboutBLDP-19-002743 r-__, _ ..,
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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�uF CITY /,l _ MA DATE PERMIT# ,(l�//'� 7'/sl
JOBSITE ADDRESS _. OWNER'S NAME 0..apri efu._Q.,.... .
POWNER ADDRESS ,. __ TEL ..... .--- .*. FAX w
TYPE OR OCCUPANCY TYPE COMMERCIAL Li EDUCATIONAL 0 RESIDENTIAL 1f'
PRINT
CLEARLY NEW:0 RENOVATION:K REPLACEMENT: ` ' ! PLANS SUBMITTED: YES Li NO
riAFIXTURES Z FLOOR-. BSM 1 2 3 411 6 7 8 9 10 11 12 13 14
BATHTUB -M . . (,, I .-- L
CROSS CONNECTION DEVICE 1...., .... ',: „ [i ::m �... .,,T 1_ �ti „.. , I
DEDICATED SPECIAL WASTE SYSTEM I „ . ;r ' �._.. �......
DEDICATED GAS/OIL/SAND SYSTEM ---ii ( i
DEDICATED GREASE SYSTEM r t � r
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DEDICATED GRAY WATER SYSTEM F 1' 1I ! t I 11 ,
DEDICATED WATER RECYCLE SYSTEM r 1 I i€ t �_, ` fl*
DISHWASHER .__�_ I L,._� t,_. ._..'I
DRINKING FOUNTAIN � 1 t :�y
FOOD DISPOSER i , 1-11 @I I r f
FLOOR/AREA DRAIN ]. II_;I, ,, £' I , l
INTERCEPTOR(INTERIOR) , - pjI 1 I I 'rail , I
KITCHEN SINK I ,,, .1
LAVATORY .. , i .,„,€L __IL 0 ' � _ L i1 4
ROOF DRAIN F r
SHOWER STALL' _ ,
s
SERVICE/MOP SINK AN —1 i 1 .1— ' LIM 'Ll_j 'r ' '
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TOILET & L,b., ' ' -... r _._...',f ,r,
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URINAL i,. I 1_ }_ 1 4.1
WASHING MACHINE CONNECTION '` 1: _ ,1 li ._. IF 1
WATER HEATER ALL TYPES --i ' 1 i
WATER PIPING sir---, .- 1 I in ,.._. r 1.. .,...� .,,.. 1 fi . ..._;
OTHER 1 ' .�.�. ..f.,A.: : in. :.:.: _ ;; . . ,..r .. ,` .
„,„,,,rr''bY"e... .,y :.x•� i.,„,,,,.. „„„,,, ...± ,xs n .-.s 1 _i e .., ,.w1. 1 . „...._IF it .., _is
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INSURANCE COVERAGE: ry5.—
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES XI NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY w 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 0 AGENT LI
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 iance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER'S NAME ,loc.,T, 1 N LICENSE# 1,159a Q 1 SIGNATURE
Mx t JP1• 1 CORPORATION 0#1 PARTNERSHIP El#1 ILLC ,,.#
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COMPANY NAME L vern i Kiel (c ADDRESS ra 71 mm I , ,, y�
CITY'CO,_at, lin STATE . ZIP Oa�070� TEL ._ .�
FAX [ = CELL EMAIL
ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
A 6ñY/1
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
// / L` FEE: $ PERMIT#
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PLAN REVIEW NOTES