HomeMy WebLinkAboutBLDG-18-000292 • - MASSACHUSEt t S UNIFORM APPLICATION FORA PERMIT TO PERFORM-PLUMBING WORK' -
n Zi"":4" awl l t4 MA DATE'-,!/�C/_ PERMIT �I�-)i a�$'Z
I JOBSTTEADDRESS Q Cr,I4--,e IV OWNER'S NAME) 6--a/ 0 ryniA 4---:‘, - 1
OWNER ADORESS 1 Y4 i TE11,Wo4W-cz t, rAxl ._-_ ... i
. TYPE OR OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL 0 RESIDENTIAL -- .
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CLEARLY N 0 - tt1NOVATION:0 REPI iCEMarr:[ :PLANS SUBMI it ED:YES 0 iki0 -
FIXTURES 1 FLOOR-' - f BSM , 1 1 2 f 3 1 4 5 1 6 1 7 ' 8 1 9 I 10 1 11 12 1 13 1 14
BATHTUB - " t( 5 r l_Ii.__.I! f, cl =1-_ _JI___-_t
CROSS CONNECTION DEVICE a - _ 1 1 I' 'I-11 it it _l I`)_-__iI--_- _i!.
DEDICATED SPECIAL:WASTE SYSTEIvi iL. _;',� --li (—;.- - t [ C17 '- -- - i !I___31 _
DEDICATED GASIOILiSAND SYSTEM 1 '.-_-I! }�_. _r - ' I• _ 11_ __I--__::_ ��'=.= —1}
DEDiCATED GREASE SYSTEM 3 ` u Imo_.('fly_ "l� �?�''-,{_ s
DEDICATEED GRAY WATER SYSTEIvi 11 _4_11- 'I L =a 1 if- =1 II ll _ ''I '1 `I
- DEDICAiEDWAtt RECYCIE SYSTEM ! I til___ I .. til t'� J I!l ._ '-1 I t'
DISH'r:^SHER - i:` .I -11�_..1�__-s 1 �I____.-1._ i��'1—�1 1-_ '
t DRINKING FOUNTAIN iI.___, i__JJL- 3 =1-7:- _ _. - .,. :I
i FOOD 1 SFoSER - III_ J I _--I �! � t rv_____:_.___J
FLOOR./AREA DRAIN I-�. �! € Fr l 1 F a!__jl
INTERCEPTOR(INTERIOR) II ;q li F. t°l._.lI____ �7[I L( _i11 ni____j:i I
KITCHEN SINK li 'l it l il _ .___.i i F1 1 (j "I if F¶1 I___ (—;1_ 11
LAVATORY 13 •1 • a t! It • t
ROOF DRAIN ii I_ _(_� _ _..__ ___it__-GI-----II L1, t(__ __;!L i_CI-_-- (
• SHOWER STALL II 11_ it I1 -a._.__Ftt il 11 _H- 91 i!-_____i1 lf._ I =.1. '
SERVICE I MOP SINK i iI i_F_ ri - I; F ;: _ `M -
TOILET 1 III si ti -ill n Ii 1 1 i; - f{__.1l—�t� �1
URINAL ii-UI =1' q I I—il 14__Il ( `9
WASHING MACHINE CONNECTIONI - 1 i;l iI i e i -El - i. • t:—( rl_II r( "_!{ -'n?
WATER HEATER ALL TYPES II ° _ i r _ .___�" I f—_11 i[( :._-II
WATER PIPING - J,_f `'1--Ji I. • <l_-.=l.-_J1___ I, i____JL___F it 'i----.-il
OTHER HER T 11 7i El 1iI '1- 11_. 1. H1_ i1_ _ f-_ _A--- SDI tl_TS FI
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: INSURANCE COVERAGE:
I have a current liability insurance policy br its substantial equivalent which meets the requirements of&4GL Ch.142. YES ErNO U
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW -
UAB11.i Y INSURANCE POUCY Z.-V.- i OTHER TYPE OF INDEMNI Y •
0 - BOND 0 -
OWNER'S INSURANCE WAIVER-I am aware that the licensee does not have the insurance coverage required by Chapter 42 of the
. •Massachusetts General Laws,and that my signature on this permit application waives this requirement. -
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• - CHECK ONE ONLY: OWNER U AGENT 0
SIGNATURE OP OWNER OR AGENT -
I hereby certify that all of the details and information I have submitted or entered regardm,g this application are true and accurate to the best of my Imnwisrga t
and That all plumbing worts and installations performed under the permit issued for this application v.ill be in, mpliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Lav s. / , - -
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PLUMBER'S NAME P h C;cLirG''CLDA U LICENSE 9? 3 SIGNATURE -
MP Er JP D CORPORATION •
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COMPANY NAME}:j' `e/ci /rivy ii Ltr-I ADDRESS Iar/ifl it-,.f/-,g' r. „iii— 6 1
CITY AiL?lfit/rd',Oci,% i+STATE -
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