HomeMy WebLinkAboutBLDP-19-004219 1 � R ck"" ,,A00 Y
MAS SACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK�j y�
0 CITY \( (•\
(O0,- -h MA DATE I I Y U
116, PERMIT# //�•DP' i�,JOBSITE ADDRESS (- f' �+
lI ).l s.. n�.A .. I, OWNER'S NAMEf .,6 GI.S 0 .1
POWNER ADDRESS . TELq1075 c51 joiFA
TYPE OR OCCUPANCY TYPE COMMERCIAL�n_..,.- EDUSIAirI CAL C RESIDENTIAL 5(1
PRINT
CLEARLY NEW:—1 RENOVATION:C REPLACEMENT:gi. PLANS SUBMITTED: Yl S 0 NOD
FIXTURES 1 FLOOR BSM 1 2 3 I 4 5 6 7 8 9 10 1 11 ' 1 13 14
BATHTUB L-. 4i~al 4771 ' _ .. .... ...............IL .. 1
CROSS CONNECTION DEVICE i[.-I. 1,_. . 11 ... ... Il. .a .._.... l ,.... , . _..t ,, ___;11_,_,A
DEDICATED SPECIAL WASTE SYSTEM II_.. II !II II En `i 1' 'I! i . .li ., I,,:. ;+ T .E..._ I
DEDICATED GAS/OFLISAND SYSTEM d , ,,1-7�] 3I I jf I r .„....,,A. i
DEDICATED GREASE SYSTEM I 0 II 1— (—.. 1 I Ill 1I , .,( .
DEDICATED GRAY WATER SYSTEM .L. ....,I 1 -1 ,' .al^-r-�i_........1 . ,;f� . li..,.,.. _(`_. 1
�T � .�i t ,.. I' t
DEDICATED WATER RECYCLE SYSTEM Ij�:�,I� u� (� q , ;,I ;���—i ;1 .�1 1!1 I! 11 I
DISHWASHER 5__.._,.41 I -11 -1!.._.-..._.I"6 , .1 -11 t in _.. 1 ..-t it .. . ...t
DRINKING FOUNTAIN .I:.__ it _:I lr.._. fl,,,_ 11 .....:. 1 ..._.11 .......li 3,. .__--.,-rk,.,.,._...&'- L ,r 1
FOOD DISPOSER i -- il 11I II 1. .!7,—.7 . . .Il I ii .. ...Ili_,,... ._. —11—..... I..... t
FLOOR I AREA DRAIN _ fl i
INTERCEPTOR(INTERIOR) ;.._._.__-;1 a -I ir—lii.....,.._.'i.. 11 1
KITCHEN SINK Ifl ill_... . .I ....... .. ,:i !II 1 .., i._.... <fa 7 f ,.__l
LAVATORY r.— 1 s •;; . -1 1
ROOF DRAIN 17 .i ;, . :1 '
SHOWER STALL 11 11. 11_. ) ill'-71 _. . I I . I II IiI I r
SERVICE.-'MOP SINK t ...._,.,� t l :11 .. .! I, .. _ `-,� „ !'!if -I< . . .,, I
r
TOILET "^ .I. ill 1.. .__. .. I' I . I I T. .1 .
URINAL i . . ..if- f _ `�i-� " t_ - 7!i 1 '
WASHING MACHINE CONNECTION ' .,.— I Al 11 _ 11_. . it ,._... °f , _.. 1'.,... 11._.,..„_it __....
WATER HEATER AL TYPES I 11 3 I 11 .. v 1. 11.... , . .. 1; _ .' .t! !
.
WATER PIPING I I 1 • 3T TTii Iii....._..1 . .Il! —.E
OTHER .......... .......... ._...._ ..._.. I _ ,Ii '1111. . 3r— 1^7ii ...(i. ! "1 f'1 1. . . .117
. 71
i .... ... . ...',,:...... 1...... 1B. ...-FI fll ...._... ! l �.., .3 ._... l.1 .
.. Ifni ,'!1- 1 11.._........I
I . ...... .. ._..... ......_........ ... ...._.. 11. . .1-1. rI. 11 ,. —, !11-:'I I , ii. , i....... .'ill. ,.. {' 'I l
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 3 Li
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY 1---1 BOND r
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 L i AGENT Il
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 c±my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in mpliance with all Pertinent proe i op of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. O
PLUMBER'S NAME;Craig Bishop .,, . LICENSE#r:1 15101 ? SIGNATURE
MPS JP CORPORATION I-71# .PARTNERSHIP # ';LLCM! •
• COMPANY NAME; High Efficiency ADDRESS 4 378 Route 130
ii
t + t ri
CITY!Sandwich STATE Ma ZIP I ... ; TEL 1508-825-3695
FAX CELL I EMAIL 1 adrrlip high-efficiencyilc.com .___. . .. ..... . .. __
uP t-f- z
a �