HomeMy WebLinkAboutBLDG-17-004052 •
y/. ( t0� (/'
.
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM.PLUMBING WORK •
-�'_ ' CITY *244 $ MA DATE '?.�_{ 17 I PERMIT#&loci-/ - 0 7
' JOBSTTE ADDRESS ''1 c)&/1fig fLT•Zg I OWNER'S NAME ET W p4-1:, oti?_v1
P OWNER ADDRESS -111 12 7- ZP, S...yI MCOW _Oki TEL ncr ggqJ'fI IFAx Jb 3'W -/ )
. TYPE OR OCCUPANCY TYPE COMMERCIALS EDUCATIONAL LI • RESIDENTIAL
PRINT •
CLEARLY NEW: • RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NOD
FDC WRES 1 FLOOR-4 • BSM 1 2 3 4 5 6 7 8 9jll 12 13 14
BATHTUB I. i_ n�� i _
CROSS CONNECTION DEVICE MOM 1i� - 1 I i' II__._ I >i -.-:' i; - 1 ( .
DEDICATED SPECIAL WASTE SYSTEM I i' I Ifni II ll MEL-__ I I! II
DEDICATED GAS/OIUSAND SYSTEM NEI '' l _;I' I' I _II _11�!�'K'�Olt
DEDICATED GREASE SYSTEM 111 S IM1I 1 .0111111 ;; W i l _11111111111.111111111.111__
DEDICATED GRAY WATER SYSTEM �11�1—hill I1 'l�ii !���II Ii VMIM
DEDICATED WATER RECYCLE SYSTEM. IIMARAIIIIIIIIIIIIIIIMItileff I.Entiiiiiii M I Minna,
• DISHWASHER !111111E111NIFINIIIIIIMLIMMiI 'I -'aim'.
DRINKING FOUNTAIN P�I1�1i II= 'I - 1 1' iI it • 'I i - '
FOOD DISPOSER • ,111.111.1.111.111M 1 ___P - ill 11111.11111111111111M 1111111' i11111111111`
FLOOR/AREA DRAIN , ` Mit - _ 1 _ � u i�__
INTERCEPTOR NTERIOR) 11 1i I . ,r�i _ I _.tr -- 1_(I1--. I
KITCHEN SINK i ii ___MEP _ •' -_ ..____I MIMI i I __I
LAVATORY nil I' I _ . I' i III 'I II_____ .1;___ .
• ROOF DRAIN I I' iI F i I t um I
SHOWER STALL '11 II I 11111•11 II M111,1111 a u I.
SERVICE I MOP SINK II _ I t______ ___ L _LJ1_11 _
URINAL . . UJiRPT±-1H-1
WASHING MACHINE CONNECTION 1I i1 I I' Ii ii II ' 1.1•01111MWM11
WATER HEATER ALL TYPES _ -i; ;i i=11 ' i I _.._
WATER PIPING ` i d i ; '� 'I
�i'
OTHER - I '. 1 I i_ __il__ JAMUL i, I' , _
I1M11 I I11MIIMMIiMiNNIi I `I�i i .
�i�J�;i�u�
I; I I_I' ill' il11111•l11•1311111li . II I' .II ;il I'
INSURANCE COVERAGE: i E 0
II have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL C 1
YES 0 NO_
IFYOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW FEB 201
7
• LIABILITY INSURANCE POLICY D OTHER TYPE OF INDEMNITY D BOND El •I J°`�`
OWNER'S I SURANCE WAVER I am aware that the licensee does not have the insurance coverage required ( IItPARTME NT
Massachu tts Gen ' ,Laws,and that my signature on this permit application waives this requirement
n Gl-( y -0/se
-- • CHECK ONE ONLY: OWNER ln, AGEM El
SIGNATURE OF OWNER OR AGENT •
t 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 compliance with all Pertinent provision of the
• Massachusetts State Plumbing Code and Chapter 142 of the General Laws. '—�
1
PLUMBER'S NAME _l� R0 Wm4.4 LICENSE#,-1 T:I`Il • SIGNATURE •
MP dP • '• CORPORATION❑# JPARTNERSHIPD#% LLCM.. .
COMPANY NAME ACILJP1 44 P/uriki-0. (ADDRESS Co
CITY '. .)/e1 f r;o t" STATE Pr)/9- 1 ZIP �f��ingillj TEL i I. —.3— 6:1 - // 1 . j�
FAX .. - I CELL (EMAIL d(.✓»'►i¢NJ Gc]r�GcciT • 11
. 1D4.5 Right of Entry.'Where It h ne®ry m make an hapa.tkm to enforce the provisions of this code,or where the Inspecter has reesonable muse to believe that there eats in a sail-cure or upon a premium'condftlon which is contrary m or
in violation of this code which makes the structure or premkefhrssafe,dangerous or hazardous,the Inspector authorized to enter the structure or premises at reasonable times to inspect or to perform the duties Imposed by this code,
provided that if such structure or premises be occupied that credentials be presented to the ooarpart and envy requested tf such structure or premises Is unoccupied,the inspector that ftx mole a reasonable effort to kaate the owner or
other person having charge or mnvol of the strucc re or premiss and requec entry.tf entry is refused,the lrspectrr shah have remorse to the rues provided by law to secure entry.
fi.