HomeMy WebLinkAboutBLDP-17-005960 < 1•:, I MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFOiii..ii PLUM 3ING O' K.
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i a t 4 ; CITY ------ _`Sow . c>Rrno,)'EA,> MA DATE 5-\1.-17 PERMIT#644P-17`O'I3T60
JOBSITE ADDRESS 3y w.\_,..... o A a OWNER'S NAME glbrea.A-d CZtarvne -\'
11114
OWNER ADDRESS SAME _ TEL tot'1.55 _yci5A3 FAX I
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL V
PRINT •
CLEARLY I NEW: RENOVATION: REPLACEMENT: / PLANS SUBMITTED: YES NO v
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FIXTURES 1. FLOOR—.' I BSM • 1 12 1 3 l 4 5 6 ' i 8 I 9 i0 1 11 12 I 13 �V -•
BATHTUB
CROSS CONNECTION DEVICE t I --IDEDICATED SPECIAL WASTE SYSTEM
i DEDICATED GAS/OIUSAND SYSTEM
'DEDICATED GREASE SYSTEM I i I i
DEDICATED GRAY WATER SYSTEM I I — I 1DED —
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I�AT_�WATER RECYCLE SYSTEM i _ �— ,i
DISHWASHER ij '.—L { { tI -- _-._ - -
DRINKING FOUNTAIN ( ; I I - i __...--
FOOD DISPOSER { _ —I I _____-'
FLOOR OOR I AREA DRAIN I - --_
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INTERCEPTOR(INTERIOR) _
KITCHEN SINK + --- -
LAVATORY } — — -----j
ROOF DRAIN k r i
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i SHOWER STALL L_ } t —T !
SERVICE I MOP SINK i t I
TOILET
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URINAL � ! --.1
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WASHING MACHINE CONNECTION - - --—'
WATER HEATER ALL TYPES i
WATER PIPING �.__1
OTHER
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of PJIGL Ch.142. YES ' NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ' 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.
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CHECK ONE ONLY: OWNER AGENT
SIGNATURE OF OWNER OR AGENT — •
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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 knowiOg: 1
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of trX
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �e 4"---Z ' d'
PLUMBER'S NAME Matt Woodward LICENSE# 30553 SIGNATURE
MP JP i CORPORATION # PARTNERSHIP # LLC #
COMPANY NAME M.Woodys Plumbing and Heating ADDRESS 198 Thurston Street
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CITY Wrentham STATE MA ZIP 02093 TEL 508-838-7862
FAX CELL EMAIL mwoody8905@gmaii.com