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HomeMy WebLinkAboutBLDP-18-003336 il•\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Ili CITY , R l y1t�� l /'1 t I MA DATE i 1 /F/) 7 , PERMIT#� / "B�i ..?.6 1, UI�/ (� JOBSITE ADDRESS , �'9 ��Gnln - , OWNER'S NAME {q�L'C_ a/<' r i) ., < 1 f P OWNER ADDRESS ___ TEI OS)3 F,3 7 Y7 i ,FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL [l RESIDENTIAL PRINT f j�[` n 9n17 CLEARLY NEW:[I RENOVATION:ID REPLACEMENT:1.4 PLANS SUBMITTED: YES Fl NOD FIXTURES 1 FLOOR—, BSM 1 2 3 4 5 6 7 6 9 10 11 12 13 14 BATHTUB af ,..J.... _ f - __ . -1 _ ' . . ( ..._. 11 CROSS CONNECTION DEVICE — DEDICATED SPECIAL WASTE SYSTEM .__-,-._.I.._. .._ J _ _ ...- (�._ I ____ _.__ _ ___...____11 ' DEDICATED GAS/OIL/SAND SYSTEM _ ._ ___ _. __ . _ ; DEDICATED GREASE SYSTEM M _ __A .. ...1 _. _ (. _ _ _;._ L.__ .I_y DEDICATED GRAY WATER SYSTEM _I---- I--- , . -.-II — -- .--- --; -_ .;1 -_- - --- .. _t-.__. -i DEDICATED WATER RECYCLE SYSTEM _ _I---.--Ii—..__ _ _.� _ ;I—_.,_,__—,I_, 1— _ I 1 _ ._.DISHWASHER [� . . -- � -�----,-�—_ ; �. _ �.�. �.._ -� �-, �[�__- DRINKING FOUNTAINa.i. . *. RDRRRRR FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR INTERIOR} -_ _. I. _ KITCHEN SINK LAVATORY ___ __ ... _ - - _ ____ i -ROOF DRAIN SHOWER STALL I-� ._ ! __ SERVICE/MOP SINK 1 i ...�,„___._ -_._._ . : i_.,,... .... 11._....... TOILET _ _.1 1 . ; _ -_._ _i 1 _ 1 URINAL I —.-_il- _ !.____ .-- _. — , _---- WASHING MACHINE CONNECTION r..._.- �,(�_ , __ �. ' _j.__, . _ _ �... -_ _, _.__ I I. ._. _ _ ___. _ ,_:i WATER HEATER ALL TYPES I___..m_If._ _ 1. 4_...,�_.... _ _ _,_. WATER PIPING __ - _ _;I. _ -- OTHER -- . . - ----- _ _ .. i I_i INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES LNO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POLICY rii OTHER TYPE OF INDEMNITY 0 BOND 0 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 1 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 ccit2Liance with all • ro ' ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Y',V,r. fYJ G. C;A e,,. LICENSE# I tom© SIGNATURE MPVi JPO CORPORATION[i#aS0 C.JPARTNERSHIPO# _�.. LLCO# , COMPANY NAME,n,.V L.. cgt,: e_. pt_k_. -�t:._. i ADDRESS -,_IL_-C,O _L�___..___._-- .._._...._.._,____._�... CITY w, /G,r ry,o,,}� ____ ..... STATE ZIP C)'p.b7 a TEL FAX sot-lei 0-ti-`15rl CELL bp))3L4-370141 EMAIL .. !'(lI. Ju!Y_? b 0 . GOrl f 4_ ,n 'p4. _ ... I 7