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HomeMy WebLinkAboutBLDP-24-322 (2) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK �= CTIY "f':--(1---'-'1 : /1/ 71 MA.DATE 3 20 2 ( PERMIT# Q LJ� 2n 3zz JOBSITEADDRESS 5 �� OWNER'S NAME�1/�iga' JCS<Qie POWNER ADDRESS '�LI 'FAX TYPE OR OCCUPANCY TY'E COMMERCIAL 0 EDUCATIONAL ❑ RESIDEHTIALg} PRJNT CLEARLY NEW:D RENOVATION'0` REPLACEMENT:❑ P!ANS SUBMITTED:YES❑ NOD FIXTURES T FLOOR-+ DO© 3 I 4 ©0000 ID m® 13 II BATHTUB CROSS CONNECT ON DEVICE DEDICATED SPECIAL WASTE SYSTEM111111111111111 DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM OW MI MI MIN MI i NM MIN INN MI N NM N M DEDICATED WATER RECYCLE SYSTEM MIK♦•iiMI all.'Illil NM INNIF 1.111 MN 111.1 M,XIV MI NM M. DISHWASHER _��_IIIIII_ ;� _NM � MI MN MI DRINFOODpDISPOSER NG FOUNTAIW NM on�,allfa aim am ammi imm NM 'NM 11111 ®M MI.; INTERCEPTORFLOOR/AREA .o4 or. uni s m m■'n ire a n a KITCHRI SINK LAVATORY ROOF DRAIN . _ — 'im"# 1 SHOvyrit STALL ; i. , ` TSERVICE/MOP SINK�ONE'f � 7sinURNAL 1 U p WASHING MACHINE CONNECTION WATER HEATER ALL TYPES III.Ali-- fall♦M MI MIN M IA!il.it Mr ill■t?• OWATER THER PIPING =. �' 11111111111111311 II II 1I mom.MA MI A.�mini maim an Pict ma ow IYriN■I�' —laN--M; ts[A INN—MI tilt :al n mace—. NsImmaimIt----ass • INSURANCE COVERAGE: I have a current JIabII1ty.Insurance polIcy or Its substantial equivalent which meats the requirement,of MGL Ch.142. YES 9-NO O. IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABILJTY INSURANCE POLICY❑ OTHER TYPE OF INDEMNITY❑ BOND 0 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 sIgnatura on Lhle permit application waives this requirement. CHECK ONE ONLY: OWNER D AGENT ElSIGNATURE OF OWNER OR AGENT I hereby certify that aN of the detaas 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 to permit Issued for INs application will be In compliance Mk all Pertinent povicMn of the Massachusetts State Plumbing Code and Chapter 142 of the General Lass. , ,.�,- 'X. PLUMBERS NAME "/s/l9�id �L LICENSE# m9d°ay SIGNA MP La JP CORPORATION 249 PARTNERSHIPD#J ILLC❑# COMPANY NAMEWJAS/il77i7i1,q !ADDRESS //�'CL'" cTTY�r/ einaiil _ 'STATE m4 al'(D2473 TELI �7N—�3ti—o 7�'Si I FAX( IC®,Ll IEMAIL //c+CPD/z1 GS7r�i` &'z. may/ 4% • t) A c C, •. 1iiMe I. II 11 i 1 I . g I III I I p 1 I I ,� Id , I I i II riOr I I Wel. p O i0W ElN WW - ILN I II I i .N.. i a . tc • 1