HomeMy WebLinkAboutBLDP-18-006184 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY XVC.0\o vi-i, MA DATE PERMIT#/ /O/ /_ .e!!LA'Y
JOBSITE ADDRESS R.4 co V kcI TY)a i h s . OWNERS NAME V010<2$ W I ink,
POWNER ADDRESS Ov A-1` Y2C-4N,sai- 07-10la y TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 2"
PRINT
CLEARLY NEW: E RENOVATION: I/ REPLACEMENT:❑ PLANS SUBMITTED: YES ❑ NO❑
FIXTURES 7- FLOOR BSWJW , 1 2 3 4 5 6 7 8 9 ' 10 11 12 13 14
BATHTUB 1 `
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM 13'4620DEDICATED GREASE SYSTEM 4\AP
DEDICATED GRAY WATER SYSTEM `'
DEDICATED WATER RECYCLE SYSTEM , \( • _
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN _ _
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY t 111 i
ROOF DRAIN
SHOWER STALL
t SERVICE I MOP SINK
'` TOILET $ 1
URINAL
�i _
C.14; WASHING MACHINE CONNECTION
J WATER HEATER ALL TYPES
WATER PIPING 1
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MG_ 1(E 0 D.....
_� IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELO\V 1
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND ❑ � r
MAY ():1 ?OM
I OWNERS INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required:by Chap 142,of the
1` Massachusetts General Laws, and that my signature on this permit application waives this requirement. - Gf r.;/. f7�_
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
.----.I 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 with all Pertinent pry,i ion of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r /
PLUMBERS NAME 1,�� 1, k,,ibt ,��'�'� Y LICENSE# j/s��j 51GNAT '��
MP JP ❑ CORPORATION❑# PARTNERSHIP 0# LLC❑#
COMPANY NAME M: J ireel Pi'i r ADDRESS ,Ra gl;ck /
CITY P'-flf $ STATE Mi ZIP 0 Zlo 3� TEL S s-40(9-7 4t(C)
FAX CELLS '" K$' 'S7t.( EMAIL w/)Cx 1 /0../e- " 1
lf /77 o
avi {n9 lreernII At' 94j)-4 g G,S*7
gillifir
0
U
00
Z
}D
z
oLID
a W o
a -
Gu cn .K
O ¢ a
W
O wcn
-
O ZO
a 7-
� Q
U
J
0
O_.
cn
Q �
2 W
_I- LL
0
VD
0 ")
0
z
4 1
z � \
o��