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Home My WebLink AboutBLDP-19-006379 MAP: 13figeEC MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK !Lief CITY VL rrn0LJ u, _ I MA DATE 054&L j J PERMIT#/?/-12/)"/1�-62:7(O1.Y .,...., • JOBSITE ADDRESS t-i LI L.Ower IA tr,pax OWNER'S NAME (2,,L c;-., . ,c r _ P _OWNER ADDRESS Lf�{ (.,(j L,UE r !�,_�ron K g TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL 0 PRINT CLEARLY NEW:❑ RENOVATION: REPLACEMENT:© PLANS SUBMITTED: YES® NO® FIXTURES Z FLOOR-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB II X 1 _. L___11 I1 f I ._ _IF-3— _IL_ I. (l ,. )L_-___._J _41.J CROSS CONNECTION DEVICE l _. 1I,__ I.=�,:rsL _�.. _J.i* -_J!_L w_,,. 1 r_ I f_-�1 ,.,,_ I____JL IL ..J DEDICATED SPECIAL WASTE SYSTEM J L, I,_-_ (9_..,,_.11______IL I L..--I t i =L_I T_,_ 3i. J DEDICATED GAS/OIL/SAND SYSTEM L I _IL U1 II______.1L ir . L_ IL__I __jI_ I _j DEDICATED GREASE SYSTEM {,_ 1 ,.J k; __, I ____ �JL___,JI _ II 1f_. _ I DEDICATED GRAY WATER SYSTEM .1 _ .!_ { DEDICATED WATER RECYCLE SYSTEM _ I__._IL _ JL_-.JL_J_I l -;f_.�.__II 1 _._a.-(]�,._—IL—IL DISHWASHER L � _&1{ _IL�____JL __P _ .L-__3IJ '�l 17— Ir 11 C_ DRINKING FOUNTAIN I 9L=__;]I �1 [1 J (L..I===_JL.- I____fl _', FOOD DISPOSER 1 ___ _I_1 _JL .,I rill. 11_,I L..-_..JL._. ILI---• .1--- FLOOR/AREA DRAIN ,I«._ ? ii—_,I_ --JL___ ,._ss Li L J ]LJL t_l___-_J._ INTERCEPTOR(INTERIOR) ( _ II_3f L _I= I__,1[____IL_AL _J[ KITCHEN SINK L_dd�� ;_-__ I_ 'L_ =A! .,II 41___IL 1,1 I - 'I—1 LAVATORY I / JI._____(L- II_T _ I_Fill[ I=I=L-�y._.JI4-,. 11.___._I_I ROOF DRAIN I 3 IL_ 1. i - 11 )L-. _J=1 z _4...s1 L JL j _ SHOWER STALL --__?I.�aI 1L__ I 'I- 1 -. 1 ii,..R,.�. 11,,_. L_ ?� SERVICE/MOP SINK L _ i_ i i 11L. ._ _1%__1___1ly..-_I! IL .e.JLLs#..,..L J I___-.I TOILET Lam!.6_1 II V _P . it _ ii ir—a,..._ ( 'I - I - 1 URINAL T IL__JI__. I_ ._._,L_ L__ fl i,. .�� ,. 1 tl _iL.,..��.1 L_..,.._.I WASHING MACHINE CONNECTION _a1,�l l_ 1__ _ I, 11 �.-- 1 L _1L 1�_.-„3I _ ILL __I WATER HEATER ALL TYPES ,I L t l i i ., i__ -(( 1 I_-- - 11..�,I II._ :_( WATER PIPING _Ji Jl � L_ 1.;I if (l ie... l _fL._ .II . I 4 J OTHER - f it_m JI :Ila_�,..,..1 L<V.=Al1 'II. _-s_Jl IL_-a_..11� .1�_- L p + s. _- �� _____11. II r _ JJ L. iL IL--]_ �Q IL __ 1_ II ..il�____Ii �_, I__. _ r _� _ _� �JL_-1�L Ji J _ JL..a_.L =L—i _ .1 ____L.....JI=I - tL r- INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Ed NO J IF YOU CHECKED YES,PLEASE INDICATE THE E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW F LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND 0 1 r / ,--Z) -CV OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of i Massachusetts General Laws,and that my signature on this permit application waives this requirement. 46 7 • 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 corrliance with all i Pert�nent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. -PLUMBER'S NAME S J1 ' ( t).i 0\ . Il UCENSE# -4"L0S SIGNATURE` • MP® JPV.Er CORPORATION D#L._ _PARTNERSHIP®#� LLCU# •COMPANY NAME Al9L«I (p I't i 1 I ADDRESS Z/ (C;vafz4,0 ` 1('1r 1- + CITY j( ), 111n /.,,-Atot :f 1 STATE f ii k I ZIP 624,6(4 TEL 'j c_OL- �4 0 Lit G Z I FAX _ 1 CELL EMAIL /n _;,,r l i,'\! ," tt,i-I`0" Lem) 1 �,21_/ • ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT FEE: PERMIT# • PLAN REVIEW NOTES 4.11. 410) • • • (Pw'r • . .