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HomeMy WebLinkAboutUntitledBLDP-18-006664 y MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK /, ' /a' CITY �� Ped MA DATE 5 Z/ 145 PERMIT#fiI�I�/"'/r'D(44� .1 JOBSITE ADDRESS hc ,e 4o �"3' t� OWNER'S NAME 1 .4 01-a POWNER ADDRESS TEL FAX TYPE O R OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL L7 PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO[ FIXTURES 1 FLOOR-4 BSM 1 2 3 1 q 5 9 7 8 9 10 11 12 13 14 BATHTUB - _ CROSS CONNECTION DEVICE , DEDICATED SPECIAL WASTE SYSTEM j DEDICATED GAS/OIL/SAND SYSTEM _ DEDICATED GREASE SYSTEM - DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN _ INTERCEPTOR(INTERIOR) KITCHEN SINK 1 LAVATORY 1 1 ROOF DRAIN ! ' ' `" SHOWER STALL 1 ! Ct; SERVICE/MOP SINK _ �fy�, I TOILET ' I'1LL / ` URINAL By j WASHING MACHINE CONNECTION WATER HEATER ALL TYPES I WATER PIPING t OTHER � I INSURANCE COVERAGE: 1,i I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES J NO 0 .T ' IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABIUTY INSURANCE POUCY � OTHER TYPE OF INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:IC 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 1.1 I hereby certify that all of the details and information I have submitted or entered regarding this application ar a 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 pliance with all Pertinent provision of the Massachusetts State Plumbing Code and Cha ter 142 of the General Laws. PLUMBER'S NAME d11 %h�r../ LICENSE# ©/2 , SIGNATURE MP 1JP❑ CORPORATION❑# PARTNERSHIP 0. LLC 0# COMPANY NAME Kelli,btlIfl(* /! ADDRESS ;/ L7//1Ji-4 /V lfrt-- CITY eberAf-at C STATE gilt, ZIP © 32 TEL 501 2 2 ) 2711 FAX CELL EMAIL I 41,)1{ JD r1 z z 0 U o� Z a w O toa. st z fxs C', o-' ►.� O ¢ a c4 cn 0 w d crJ p o c.{ a � Gil � U o_ a Q � to W H O z O N U rs� U) z Cy c4 0 P4