HomeMy WebLinkAboutBLDP-25-552 MAP: PAReee
MAR.QeetHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
A crTY( YarMduse6y' ( MA.DATE PERMIT#1 t)P.ZS-55L
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. JOBSITE ADDRESS( I L $di C is C.; ') (2a'6 K I OWNER'S NAAE -5'v 10(1 Fire e-bo 4-n
p .OWNER ADDRESS TELI •,/ frAX
'TYPE OR OCCUPANCY TYPE COMBERCIAL D EDUCA11ONAL ElRE�ENTIAL i�
CLEARr
LY NEW:❑ RENOVATION I REPLACE NT:0 PLANS SUBMITTED:YES❑ NOD
FIXTURES 1 FLOOR-, mac 1 1 I 2 J 3
# 4 ) 5 1 6 1 T 1 b J 9 1 10 11 1 12 1 19 1 14
BATHTUB A
IMMO .1CROSS CONNECTION DEVICE L , • `
DEDICATED SPECIAL WASTE SYSTEM ~
DEDICATED GAS/OAJSAND SYSTEM •
k
DEDICATED GREASE SYSTEM , , N
DEDICATE)GRAY WATER SYSTEM i ,, t
DEDICATE)WATER RECYCLE SYSTEM , 4
DISHWASHER
DRINI4NG FOUNTAIN
FOOD DISPOSER / y ,
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK • ea ,LAVATORY it , I
ROOF DRAIN r s as 1
SHOWER STALL
SERVICE/I SINK
TOILET r re. r
URINAL * r- + a A wee _ ,
WASHING MACHINE CONNECTION as. ‘ `
WATER HEATER AU_TYPES. n
WATER PIPING ,
a w
''k[ INSURANCE COVERAGE:
I have a current Jiabfilty Insurance policy or Its substantial equivalent which poets the requirements of MGL Ch.142. YES Er NO Q
CHECKED YES,Pt PaSP INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
c I TARN ITl'INSURANCE POLICY Er OTHER TYPE OF INDEMNITY El Boo❑
•
°" omen INSURANCE WAIVER:I am aware th t the Ranee.does not have the insurance coverage required by Chapter 142 of the
LLI _ *smash, awes General Laws,and that my signature on thin penult application waives this requirement.
0 .�. CHECK ONE ONLY: OWNER❑ AGENT❑
{ SIGNATURE OF OWNER OR AGENT
Tw*certify that ek of the deb*and In on I have subm9Ead ar entered regarding tins application
are true and ate to the beet of my knowledge
Ct -` rind tot at pkarrbl g work end Imbibition perbmred under tbe pant Issued brigs application w19 be to conroRerca with at Pertk nt provision of the
bleasachusets State Plumbing Coda and Chapter 142 of the General Laws.
•PLUMBER'S NAME N AU 4Y'l 1d-fi-r LICENSE# TY V{$D L( ,34,114.1 SIGNA
MPS- .IPD CORPORATION ,'{Q (PARTNERSHIP❑#( f U.CC7rcl . f
COte ANY NAME L .-Pa ti n 91,t M.1 ; A c I ADDRESS J I t ('ekyhQ .-1.-1CITY 11,.)•�rtG-rr TC� M( Mill 21P( a e ( trjl.4 r7 j { Tad -4,36-0`t g'{ (
FAX( } In. `CT !EMAIL 1 Ink.(s.n.¢8 fit G-ri 1 r>?<Boo j..C®r.
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