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HomeMy WebLinkAboutBLDP-24-714 InAP. PAgcEC . MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM PLUMBING WORK ct. ,` ;t CITY Ya/ An Q cK'4` , MA-DATE PERMIT#R CD,-2.`/-7i T JOBSITE ADDRESS 3 M V PO VA R Of OWNER'S NAME S h t I Et FO tiO I E 7 P OWNER ADDRESS 1 TEL IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL f , PRINT �,/ CLEARLY NEW:❑ RENOVATION:a REPLACEMENT:El PLANS SUBMITTED: YES❑ NO[❑ FIXTURES- FLOOR-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB = L_T1)__ .i,I . 1 I._.-.._.3 I� _ ; CROSS CONNECTION DEVICE v - I ;'_,_,_Z, 'I_ _1 .,� _J ,I _ _I_,_ ,j DEDICATED SPECIAL WASTE SYSTEM ___ 1 _,J _� [_ —_ ,� . DEDICATED GAS/OIUSAND SYSTEM .. _ _AL____i _'[ ia__ L .i _ .i .. .. ._'MIA DEDICATED GREASE SYSTEM .__ � I, �! L . �_ �I . _ ; . DEDICATED GRAY WATER SYSTEM �� _T_ _- s .I_ i® _ _ Mt jL J DEDICATED WATER RECYCLE SYSTEM il! !*kWII• , _jl _ 9 ?Mini DISHWASHER MI i._ . IL AN _ : _ 1, __ L___1 I I,l DRINKING FOUNTAIN _Mlfl LR FOOD DISPOSER � `� _ ',1 IL; . M _ _ MT FLOOR I AREA DRAIN U�!�= ,yr_ in _'. . '=L 1 INTERCEPTOR(INTERIOR) ( 1 f _ PM _ .. _ _ I SHOWER , URINAL `i___._._I _.-..I_y.._.;I __ I 1i�_ I �,_a t—J WATER PIPING 1.-.. I .,..-.-I __....,_1 i 1 � —.5 _ -,? - .I1 _I -et OTHERL I I L..� ICI-_ i j . _ =�._-._. _` .. dG . _I_ __ .____ _ IMMIX INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL R.,142. YE Ii' IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY[B'' OTHER TYPE OF INDEMNITY -1 BOND ❑ i AUG 212024 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage requited by--Chia rat?�,o ho ENT I Massachusetts General Laws,and that my signature on this permit application waives this requirement. ey __ CHECK ONE ONLY: OWNER ❑ AGENT ❑ 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �� 0 A ,e7F, yi PLUMBER'S NAME Nia...An 1 S Yr\ 1.96(-A- - I LICENSE# YYI 1 it)`I SIGNATU MP JP© CORPORATION# , q PARTNERSHIP❑#� SLLC❑#, COMPANY NAME al., -P8 t T Pa'd-1 4"C'(1 c _ ADDRESS eel,m Q CITY Vj. GZ 2mr;liirliN I STATE MA I ZIP 4).2 to')3 TEL 774- 36-6 f 8'1 FAX I CELL I EMAIL 1'Ct.(s.L1- A i>,6-5 i . P-o L. it. - _ - #: ..) ',_.-;-. - --.,_ .: - - .> sna,'- - r ....,„m , „.",-..„, m ..,..„...„..,..„ _':-- -,, ._ .7, rii rim - .. ....,-.., ... ' ' .... CI 4,, -,_, --.7-7--,' - 1,,--- .--,-, , _ , > we a. m .:. < . • ., _.., trt -,;_,,.,-,:;„..e.,.--v. ..* . .:,.... _. """.. ' ,..:,t,_. 11- Z c rn c. ov) ..T.) ..-::,...-. tr) ,-- . , ... .. . _ .�.�.�. h 4. P14: 41F '-::*iiiHriii:‘ .- x Om ..... ' ... _r_„,,,,,,,,,,,,_,_,..-, _ ..,.. ...., ,_ .. -'" ,.. ,. „._ _ ..... .... ._ ... .,, .._ ... .. . . ,,,,,.-_,..v._, „.... ,_-:., . _._. __,. ...._.„...vm. c.;.„-,-, z „ . v m 73 . ♦e s .. .... „.___ _m - lot__.... , .. 0 0_ , Adir.111111116%-- C) -- :-:4L'--,:i. -, ....-Z-- —:"Al - ...:." - .11.' r - ,w_ z.. . ' 0- -.:... _ ...... it_ .. . _ . . _ . ,. _,...,..,.. .m , „....„.. .„,, ..„ ..: r . _,-, rm . ,_..v.).- C is- - ,-.„,„:„.,..„.„..,* :.... y._ _. ..,_.... ,..,, . _.. .. ...„.... ....,,,,,,,„, 4 . ._,,,-------.0...i'.-„,-,:-, :„-2,-„,,,,,- .-„..„-, _.,.,.-_,__,..v.._,-.„.„.,,,,, .....,_._„, ,,,.. _,.._. ._.. . C 0 -....i.,.': • -,iirmot- - -'::1011 > - z,i,,,,,:....;1-,-,:;,,,,—. 1z,:::--1.cr•-:--.-41:,,- s..,;:.,,,,,,:,..,.,-___-, -- 7 -----'''''''- '14---;:"-'--11''''''''''4> Z. 0 lit a'rt- 0 ,.. _ _., ` _ ., 0 > , , ' . • 1::: 1 - rt - - , , _10".... 0 ...',77'_,..-.:'F y , ." , fili,_ _, ,_„,..,..,,, _ ....„. :___..,..r_7 -,4.-..-.--,,-1-77.--.7-t:7.=;-_-5,,,'r_.,_.1:4:41,,,i.".-,'-'N - jii ° � = �.Y.. _y 3. .�'iae# �'rt'ee�3rS.� .�}?l :F..i _ E �MY { ,,3