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HomeMy WebLinkAboutBLDP-19-007070 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK . —ij_ . CITY 4 . \,/A te all) [ - —1 MA DATE I i q PERMIT#Beelf'150 7670 JOBSITE ADDRESS 4 14.L 1-rG 2,/, J OWNER'S NAME CI.Ao y lit n 00 re n 1 P OWNER ADDRESS — . I TEI ng),9Wgig I 1FAx TYPE OR OCCUPANCY TYPE COMMERCIAL© EDUCATIONAL 0 RESIDENTIAL 12 PRINT CLEARLY NEW:® RENOVATION:© REPLACEMENT: PLANS SUBMITTED: YES® NOD FIXTURES 7. FLOOR-4 l BSM _ 1 2 I 3 4 ( 5 6 7 8 9 10 11 12 13 14 BATHTUB 1_ PIM 1--7 _ ..i' Jilin IMIX'111111111111111111,MR '' CROSS CONNECTION DEVICE *Mt (� DEDICATED SPECIAL WASTE SYSTEM MIr ;1 1 DEDICATEQGASJOIUSAND Sj STEM ___ _ ' � DEDICATED GREASE SYSTEM a __ ., _... _ I.l __ ___ ' .-_ I 1111111 I ._ _ DEDICATED GRAY WATER SYSTEM jai�,, V i 1 1= !MI1 11 DEDICATED WATER RECYCLE SYSTEM UIRUEIIUL DISHWASHERDRINIQNG FOUNTAIN T 1 _ FOOD DISPOSER I i Ir ! ' M�^—' I ______, I: _ FLOOR 1 AREA DRAIN ____________MIA_;1.„awn, i i i 11.11111.11, KITCHEN SINK =WI -- i _-_- I LAVATORY . _ I_ _ ROOF DRAIN R .ALL li. i__ _ -i _ __ . .._' i i 1 SERVICE/MOP SINK ; ;j_ I i! 1 TOILET it_ 1 -._ . l WASiv4.4. I"; .1 ,.,, , _ i 1 I .I r � D I, ian nut I e -I i- u 555 WA WA1PINGi - iliiiiiilla 131121 1 1 111111111MISFRELLEE '.-. ,, ',',_ _ , .__ ntimumprigimm_ I' 4 ' 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 i3 OTHER TYPE OF INDEMNITY ® BOND U 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 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 of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in mrceilPnca with all G �ro ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _ r tf PLUMBER'S NAME KeA). r_-h,/�_o.D r;c f . . I LICENSE# I (9 a0 ! SIGNATURE MP El JP® CORPORATION Yitt,.0736tY C 1PARTNERSHIP®# _ ILLC®# _.- COMPANY NAME _ 1,6,_Vi ce!,:j e... .A.1 _ .a..,_ ADDRESS -. Jl, r .Cir ,_ar-it ___.__ . J CITY, 1 /. Yc„,,- av4A STATE (y)A I ZIP 02.67; TEL es -7 j FAX 504`r l o-titx1 CELL,g09 3t4-3?$EMAIL . _ . krei G.D.I.u m b_ 0 C M l_Gt `1._0 0 e- i