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HomeMy WebLinkAboutBLDP-25-403 t IU ASSACHUSETTS UNIFORM APPUCATION FORA PERMIT TO PERFORM PLUMBING WORK '� CITY 1 S,/4-1 16 C/ /I t MA DATE! s/c/�s 1 PERIE#e-A P-4 -Ho3 JOBSITE ADDRESS 147 14rkers %'PGL( Ril 1 OWNER'S NAME pss:P�/ ,-LL/<r ip OWNER ADDRESS I SO Adn5 Rd. 8('.(2(l%qi7 f Al.* I TELr O ‘7 )-J,�'r 'IFAX ;, u TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL Fia CLEINT ARLY NEW:Et RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED:YES 0 NOQ FIXTURES 1 FLOOR-4 saM 11 I 2 I 3 I 4 1 6 66 7 8 8 I 10 11 I 12 I 13 I 14 BATHTUB �11�11 III A III II i 11 i===c--.`? ;I CROSS CONNECTION DEVICE I 1! 1:1 1771 IF—II ) r 1 i,�,_.,a DEDICATED SPECIAL WASTE SYSTEM L.Ji 11 - 11 JII 11I it o f ', DEDICATED GPCSIDI 1SAND%ISIS% ` `_1 DEDICATED GREASE SYSTEM =1 III f(-1i=;1-7 I I )T—T TT! ;r (—1 I 1 DEDICATED GRAY WATER SYSTEM 1 11 III lil_.___ff f !I-111 I f=(—e—( E' DEDICATED WATER RECYCLE SYSTEM `11�If-1!I A A :'IL—IE Th—`II !FII (II—t1--i DISHWASHER II f—il.�'�I�PI �----1 !I_____,J— �i DRINKING FOUNTAIN " II III 11 11 I I ii j'I-_a�L =k FOOD DISPOSER 1— --III il( )II IiI_�'1 II ,(-�-A----, — ; d t!f FLOOR/AREA DRAIN L=�1 11 t h_>I__L_ I=;f— � 71 ;-7 ,( !I —1 INTERCEPTOR(INTERIOR) _111 f —1!I_JII �1 _ : hI !i_; �t 1, `,1 ' KITCHEN SINK � '' L�I 'I 'I'--' LAVATORY 1 li "� 3! i(—ill iII I t 4ai u„ [�—':I—'r ROOF DRAIN 'II I 1'I = nr �- SHOWER STALL ��i' I it III ill II I f � i I J I SERVICE I MOP SINK j •I IQI II =,f—'ll ;!I al ,,,I1 :i "f ';'I ,i— TOILET —1i I 'I Jl _21� 1 — L+( 'I II I IC -%_1j URINAL '—il L IlI�l ! i!i 1J11 ?t l '1 1 ill WASHING MACHINE CONNECTION )—fC�I IiI t1 111-1 II II FI f— JT—'-I-71—III ) WATER HEATER ALL TYPES it II ! ➢1 !I 11 Inn d II Pl I WATER PIPING I /1 IQ 111 I't IU II 1 f I t I1 I 1e I OTHER f(-1=1 If II t1-71 I. I E T I i,I l 1 d1 L—\-;,t.f1 ---_EI 11 j 1171ill ',If(-1— I I E—I ;(`T,(�—; 1 t—:I IL_JI 1=i=I Il l`I. ?r""L__1 :t�. I- 1 ii 111 i ll7-1:-111 7----17"--1 11-1i =f`11 °f—, IN6UIIANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES© NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BON BELOW LIABILITY INSURANCE POLICY® OTHER TYPE OF INDEMNITY 0 BOND Ej •OWNER'S INSURANCE WAIVER:I am aware that the licensee grass not havgthe Insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that oil of the details and information I have submitted or entered regarding this application are true and accurate to the beat of my knowledge and that all plumbing'worts and installations performed under the permit Issued for this application will be In compliance with all Pertinent provision of the Massachusetts Scats.Plumbing Code and Chapter 142 of the General Laws. _, ;'rm io,C S�bjn'w. I LICENSE# 0 I PLUMBER'S NAME --)- SIGNATURE MPf]. JP CORPORATION UPI i1PARTNERSHIPO# LLCD# COMPANY NAME I0'reymPJ((tXI { IADDRESSI a.,j u-c Ril • i CITYLp. ra, 1 STATE i -I ZIP) [7!/yeo...._ t-s) TEL cj'1:C4-(S�/ itFAX _Qfs( CELL EMAIL 1 Sdbo., LOCOn rL611(2+I , 01 1 AJ S 7M -f a i y % a ,. - _ r }t ry V ' iz..;r... W ,_s _ .. ro r!; .i .. , „ ', . , . `"dolt `c..r tt k e 9d L re. .. ai `J f t` -..L Pp:r -�W S i . ., t_ __•. .� #. i 1 j. t { x 0. ` • • ! • vt # 6 x •�Cd . e3:. f '," ,..ta .i J `lf ,: `Iw 5 ._b t . ,'.t:: i-::;a3 )',:' ' . 5•` .. ' _ . a . ,. !x,:A�: i ' ' `r $,stalll. 4 { ., ,:.i. E.> r.. .:_ ;.fir + j. q : .. 'i ,itf'i ,i[?afi-P t.... • • _ Z'. .. , .. 1.._-;' 1517 014iii IIi to .•_ r • 5. r :