HomeMy WebLinkAboutBLDP-25-184 7S ,DO
RECEIVED
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/` PR/2C�a• a C MAR n5 2025
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.1s ., MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFriMfllr
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CITY I yG% ►' Pl l z, u+In MA .DATE PERMIT#
fJOBSITE ADDRESS /t b C MA- z' OWNER'S NAME M C'13.e e✓ z•n fr`,r or 15
p OWNER ADDRESS I I TELL IFAX
L TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL 0
‘1 PFUNT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:[t1" PLANS SUBMITTED: YES❑ NO®
FDCTURES 1 FLOOR-, DO 2 3 0 5 6 7 8 0 10 11 12 13 14
BATHTUB 1111111'
' MI'IIII mai in;
CROSS CONNECTION DEVICE '—
DEDICATED SPECIAL WASTE SYSTEM :
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DEDICATED GAS 01USAND SYSTEM WIIII
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DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM ME mar
DEDICATED WATER RECYCLE SYSTEM ME ; : .1 • . ! .: ,: ,' ���DISHWASHER •
DRINKI FNG OUNTAIN iiiimarmingnonnatimminst
FOOD DISPOSER li;111111 NE:I•'MR; ,I•posiiimii,pm gm am,a NEC
FLOOR/AREA DRAIN •
INTERCEPTOR(INTERIOR) n1_II,
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KITC SINK
LAVATORY _
HOVVER STALL R: .• •. .. •
SERVICE/MOP SINK nusinoN •. �:����'
TOILET NAM l,
URINAL M_�,-'am am ilMilil fiff ill Mil is ' i ,
WASHING MACHINE CONNECTION no,u I• mom . mil;
WATER HEATER ALL TYPES A IMAM'M NMI . ice. ;
WATER PIPING 1111111, ;:M�,MN ate; '
OTHER I�::�; .I :
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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 l--NO ❑..
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
tIABILRY INSURANCE POLICY la OTHER TYPE OF INDEMNITY[] 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
. 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 �J-#'i"4%5-A .l;t1 j j-7-e. J LICENSE#I/72' 01 1 SIGNA f� '
MP[r JP 0 CORPORATION
3q IPARTNERSHIPD# LLC0#1111111111111
COMPANY NAMEI ,l///2j/05 )"- ( C ADDRESS //('io, ,I 7--
MY'Ai y}A?/-17 el-1.;1/ r I STATE[�,: ' LP I ;.7 4"2' 1 TEL 77v.,f.'4.e5) r 1
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