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Home My WebLink AboutBLDP-17-001149 DWI P : h?A e 6( : zi p St' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK j� CITY C _1/A(/y D VII MA DATE ei Vifflu[ PERMIT#440/277—OJ/y? JOBSITE ADDRESS 36 An- J€'r., b . OWNERS NAME eerie. L -t iii ere 1 P OWNER ADDRESS — _ _ _ J Tat 13)467 774FAx TYPE OR OCCUPANCY TYPE COMMERCIAL© EDUCATIONAL 11] RESIDENTIAL PRINT ��/ CLEARLY NEW:Li RENOVATION:® REPLACEMENT:l PLANS SUBMITTED: YES 0 NO❑ FIXTURES 7 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 1 I i CROSS CONNECTION DEVICE _ -.- __ ' DEDICATED SPECIAL WASTE SYSTEM j __ _ ! __—_ a _ I) DEDICATED GAS/OIUSAND SYSTEM ___• , .__ 1 I DEDICATEDDEDICATED GREASE SYSTEM ii T 1 1 I � annum.* . UFOOD DISPOSER .RRUR III \ 6,_ iii _ _ 6.....ft....8 , _ , ,,— INTERCEPTOR(INTERIOR) . • KITCHEN SINK { . LAVATORYim gn-iiiirw ougutoute ow ; .i � _ ! lai SERVICE/MOP SINK , _\,_ ! Aar _ _ TOILET 1 WATER HEATER ALL TYPES Ivo II iniummilli � _ ' '..,mow-.. .; __..—._ -,-•--_.�.�..tea.-_._,--^—-.-,.�a.P_.z _ �, ---- -'.r.�-_-._ _ .- , _. _ ._.-. I-,.- _-,�._ - : .',�_- — INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ' NO L IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 1 OTHER TYPE OF INDEMNITY ® BOND Lj 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 i 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•• t of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in mm nre with - — t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Pr PLUMBER'S NAME ,e -f, _G„5r,.C)e- - -, ILICENSE# I_(.2a0 ! - SIGNATURE MP' JP 0 CORPORATION# ''$( l t 'PARTNERSHIP®# COMPANY NAME t,_(m .;,,,.�✓�+ _ ._, ADDRESS )1 (7_,D !le$„.C..! Pcc --__ __ _. _ _ _._ _ - CITY w,`%r ry,0y•41) ___�1 STATE ()IA ZIP 0 6;73 TEL (j0E)-7-75`-4 4. _ FAX 5of 79 0-6'61 CELL _ 1 EMAIL _ .. ti - _ _ SEPoQ2016 it c)/("176 9c0,61.