HomeMy WebLinkAboutBLDP-19-006613 . 1.��. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK J
•:_m'itr + CITY TO.t'yvo►111k ] MA DATE d S/a(f 1ct PERMIT#f1•0P 9-00 6/fl
JOBSITE ADDRESS t 3ak StihS.C2,4 D r- ia, OWNER'S NAME TyhalAn,.f cc aAicky\ 1
P OWNER ADDRESS 3a cumer Q- S a TELL?- -i a(a ..41 f-AFAX L.
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL Q RESIDENTIAL 74.
PRINT
CLEARLY NEW: RENOVATION:1,4 REPLACEMENT tik I?+/6 PLANS SUBMITTED: YES El NOV"
FIXTURES 1 FLOOR-0 BSM 1 2 3 4 5 6 7l 8 I 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE ._ \ _
DEDICATED SPECIAL WASTE SYSTEM +� x
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DEDICATED GAS/OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
_
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER I • _ _ , • j
DRINKING FOUNTAIN1
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FOOD DISPOSER
FLOOR/AREA DRAIN • I
INTERCEPTOR(INTERIOR)
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KITCHEN SINK
LAVATORY 3 1 ' -
ROOF DRAIN
SHOWER STALL j A
SERVICE/MOP SINK
TOILET e_ y.
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URINAL
air
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES t ��
WATER PIPING T
OTHER
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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 fir NO i I
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY D( OTHER TYPE OF INDEMNITY BOND
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 inr
pliance with all Pertinent rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. n ///7
PLUMBER'S NAME IR.y 1 CI O.J-k p LICENSE#L(O CS' SIGNATURE
MP,
MP, JP 3( CORPORATION 0#r JPARTNERSHIP. ,#. LLC !#
COMPANY NAME ADDRESS I /99 /D NCI�"�p NVS' \NA V
CITYr 3 bus 1 Q —f2 STATE tA.Pc ZIP 6 Z'{p j/ 1 TEL 5-0 . �/. ,IPS
FAX F---- CELL L 1 EMAIL V I 6/0 Cry'"\C,AS`t• rt,E -
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