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HomeMy WebLinkAboutBLDP-24-672 /BHP: PAQ C EC MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK :1j_'.��__---_ `� t�3l6 r1 Zl1— (a?2 1=_ CITY ya/k'V, a„r l Z1 II I MA DATE. PERMIT# U �'r JOBSITE ADDRESS 3 3 i✓t k 1\ )c�AN R G OWNER'S NAME 5 h . i c t F ,LA.; iL POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL(i , PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Di" PLANS SUBMITTED: YES❑ NOD FIXTURES 7. FLOOR--► BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I L 'r_0 1____1i _.JI t= ii - - i I CROSS CONNECTION DEVICE ` —11 _ti l-: .-_ti__a 1 _III _ _ DEDICATED SPECIAL WASTE SYSTEM IE I "l. 1,'_ {�__�i,_..___#LJLi. _ ___L 'Jl'-___ I , , DEDICATED GAS/OIUSAND SYSTEM `___ Il 1 G —L_—tl L�L._ _i�,.�_ _k_Ji _ ti=! — DEDICATED GREASE SYSTEM _P—.j i_ ' , .I_.___1=1 JI DEDICATED GRAY WATER SYSTEM I fl _,I_4I_�z—.Fli,,,__j1 i1_ DEDICATED WA I ER RECYCLE SYSTEM 1 it i ' j: _ _ ,I I-1 DISHWASHER :_ {I _ - : '1 .___,,,it______ DRINKING FOUNTAIN _� -.�I ' __.I.�- FOOD DISPOSER " _ I i� IIti r ? _jl FLOOR/AREA DRAIN , _ - _ _ 1.. _---illir'.___ 1_. 1 - _''. .,,I 1 INTERCEPTOR(INTERIOR) i _ _Ii I r __ a _ ii IW . 'r t f KITCHEN SINK ' __ I._ _: , '.' r rr,��i i - 1 - v LAVATORY , 1 _ r� _ _ViI,, a _ I— i & '1 _':______J ROOF DRAIN Ti ` . ,I�'' ' SHOWER STALL � ,I�; ____:1_____1[I.. . I>`1__ '_?1,. __JL ! 1.-9. SERVICE I MOP SINK IId�_�� ' _� i TOILET _ _...�_.,�L __o' P—L URINAL I I. if J J i WASHING MACHINE CONNECTION I /I,,,_I JI _ 11_. - =,11.__, .,IIt_!«$II E___I WATER HEATER ALL TYPES .( _yIl +i_ _ -i ! ! _—_ I 1 al ! I WATER PIPING 1Q, (I 11 I��...1 Il 11, ,1 9;._. .AI 1 —1[ -1 j OTHER it __ 1Le._1[ I—.JI__....—L_ 11 �I .II_--- -.. i _ II aL-s-_-.I�..> I _ _,_ __ LI tL-129 11 I li I v.:4 1 is IL__I 1 f L f INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO Q IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Er OTHER TYPE OF INDEMNITY ❑ BOND ❑ 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 Li 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. PLUMBER'S NAME ALS tin b-6-( r LICENSE#/VI4110t-1 SIGNA11J - MP®' JP DI CORPORATION 1,-2 �Q !PARTNERSHIP©# LLC❑# • COMPANY NAME Act, $a to 9+K:rn c I ADDRESS &w...? CITY Lij. Amta-14N (STATE mA ZIP 0.26r73 TEL 774- 36 —OrIg`( FAX . 1 CEi L- 1 EMAIL (.a,(,.n_e p n,U . -1 o L. Co". .. ch 50 -fsL