HomeMy WebLinkAboutBLDP-16-004367 /I�fI P . Pi4R e EG : orb c-� itt u
c., MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK o�
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_ 1- ;4 CITY f YA (M3 u r14____.....1 MA DATE I/;j,r3/J(: 1 PERMIT# /Jl4/3"/( '0'0
JOBSITE ADDRESS C; k S i"r�+I OWNER'S NAME 1) v,(-) t'J,-)Grit UI)rt[I 1
POWNER ADDRESS — _ TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL Ij RESIDENTIAL 21
PRINT
CLEARLY NEW:® RENOVATION:0 REPLACEMENT:Ii PLANS SUBMITTED: YES® NO®
FIXTURES Z FLOOR—* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB ;; /i . ,i 1 ,i I- J. _.
CROSS CONNECTION DEVICE (K ,I , _ _ ;. I ._ .. WIWW!!WK
DEDICATED SPECIAL WASTE SYSTEM ni_ __ __._ II I .I !I
DEDICATED GAS/OIUSAND SYSTEM . ._ _,,_ , I; I. !
DEDICATED GREASE SYSTEM __ __'I !
DEDICATED GRAY WATER SYSTEM ! - ;! _ ii 1r f 1 I_.. _.
DEDICATED WATER RECYCLE SYSTEM ,.._ I _ _I_ _i i�._, I - I II
DISHWASHER .';. _A, _. ._ .
DRINKING FOUNTAIN M'; II '__ =; I
FOOD DISPOSER _ II �.5I 1 ,. II !j�i
FLOOR/AREA DRAIN t_- 11111 ._ _ _ i -_ ! . _ I
INTERCEPTOR(INTERIOR ; t._ _ I. _ . ." _ _- .__ilea
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KITCHEN SINK T r m 1
LAVATORY no: ( ! ii
ROOF DRAIN �j .
SHOWER STALL
SERVICE/MOP SINK 1111 _ ,. 'I 111111111.11111 jl I I I
TOILET
URINALRRRRRR'RRRRRRRR;� � � ��
WASHING MACHINE CONNECTION j1IIiW 'I ! iill ;Iii!llI
WATER HWATER PIPINGEA R ALL TYPES f _WIIIIIIIIIIFR_ IIIIlIllrlliWillii
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OTHERORMININIMMinnigi ! filliffillitilli
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES If NO Ej
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ® BOND Li
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 Q AGENT 0
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.. my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in cc oanc,3 h io-rtinent• .vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. il
PLUMBER'S NAME Kell;r_,.fi_G„ Ci _ I LICENSE# I_ ivao f SIG ATURE
MP JP 0 CORPORATION yi#o2$C- C. PARTNERSHIPLJ# J LLC[J# - i
COMPANY NAME ADDRESS '
CITY__.w,,11 ,i).,52.„4A STATE ZIP op.to'3 TEL 5 0E 77 . es-4 _
FAX bof 7'1 0-61 CELL EMAIL
FEB 01 201 (le tt-
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