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HomeMy WebLinkAboutBuilding Permits (6)-CN- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK WjCITY POWNER TYPE OR PRINT CLEARLY I Yarmouth I MA DATE 22 June 2015 PERMIT # IXV 10 /6 -w0o'17 JOBSITE ADDRESS 534 Winslow Drive Buikfinq #3 1 OWNER'S NAME Yarmouth Housin Authority ADDRESS 1534 Winslow Drive TELI 508398-2920 FAX 508398-1930 OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL ® RESIDENTIAL®+ NEW: © RENOVATION:® REPLACEMENT: PLANS SUBMITTED: YES ® N0LJ FIXTURES 7 FLOOR- BSM 1 2 3 4 6 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION ALL TYPES n I1 Fv R-PIP G s_ `" X TH R INSURANCE COVERAGE: I vex tali 1 Insu_rance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ®+ OTHER TYPE OF INDEMNITY® BOND 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 signature on this permit application waives this requirement CHECK ONE O WNER ® AGENT SIGNATURE OF OWNER OR AGENT i hereby certify that all of the details and information I have submitted or entered regarding this applicaF:b�lte to the best of myknowledge and that all plumbing work and installations performed under the permit issued for this applicat'ron will Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Anthon Centralia LICENSE# 15380GNATURE MP� JP® CORPORATION# 2998 PARTNERSHLC®#� COMPANY NAME I CAM HVAC & Construclion ADDRESS 130 North Gatewa CITY Winchester STATE MA ZIP 101890 TEL 508 505 8601 FAX 4012327290 CELL 5085058601 EMAIL tcentrella@camhvac.com a1I IVISIOR OF PROFESSIONAL LICENSURM DIVISIOP OF PROFESSiO N L LICENSU sE OF CAMHVAC-01 KESTANO ,4ll%. r CERTIFICATE OF LIABILITY INSURANCE DA6122/2015 (MMUDDITYTY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endomement(s). PRODUCER Rogers & Gray Insurance Agency, Inc. 434 Rte 134INC,No South Dennis, MA 02660 TACT NAME: Kelly Estano, AAI, CISR PHONE FAx (877) 816-2156 Ed), AIC No: AIL ADDRESS: kestano@rogersgray.Com INSURER(S) AFFORDING COVERAGE NAICY INSURERA:EMC INSURANCE COMPANY INSURED INSURER BARROW MUTUAL Cam HVAC & Construction Inc INSURER C: GREAT AMERICAN INSURANCE COMPANY INSURER D : 116 Lydia Ann Rd Smithfield, RI 02917 INSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT VOTH RESPECTTO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1NSR LTR TYPE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY EFF (MMIDDfYfYfl POLICY EXP IMMIDDIYYYY1LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR X,C,U 5D1.67-32--15 0810212014 08/02/2015 EACH OCCURRENCE $ 1,000,00 PREMISES Ea occurrence S 300,00 X MED EXP(Any one Person) $ 5,00 X Contactual Liability PERSONAL &ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER POLICY O PRO- JECT LOC OTHER: GENERAL AGGREGATE $ 2,000,00 PRODUCTS -COMPIOPAGG $ 2,000,00 EBL AGGREGATE $ 2,000,00 A AUTOMOBILEDABIDTY I ANY AUTO ALLOWNED SCHEDULED AUTO$ AUTOS NON -OWNED HIREDAUTOS AUTOS 5E1-67-32 --- 15 0810212014 08/0212015 COMBINED SINGLE LIMIT Ea awdent $ 1,000,00 BODILY INJURY (Per Person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Perawdent $ A X UMBRELLA UAB EXCESS DAB X OCCUR CLAIMS -MADE SJI-67-32 08/0212014 08/0212015 EACH OCCURRENCE $ 5,000,00 AGGREGATE $ 6,000,00 DID X RETENTION$ 0 8 B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNER/EXECUTIVE YIN OFFICERMIEMBER EXCLUDED? IN (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA 1766A 08/0212014 08/0212016 PER OTH- X STATUTE ER E L. EACH ACCIDENT $ 1,000,00 EL. DISEASE - EA EMPLOYEE $ 1,000,00 EL. DISEASE - POLICY LIMIT $ 1,000,00 C Excess Umbrella SBE 0993821 00 08/0212014 08/02/2015 Excess Limit 5,000,00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if morespace is required) Yarmouth Housing Authority is included as Additional Insured for General Liability and Excess (Umbrella) Liability, for ongoing and completed operations on a primary and non-contributory basis as required by a signed written contract or agreement With the Named Insured. Yarmouth Housing Authority 534 Winslow Grey Road Yarmouth, MA 02664 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. REPRESENTATIVE .. 7�- ACORD 25 (2014/01) ©1988-2014 The ACORD name and logo are registered marks of ACORD reserved. 116 LYDIA ANN RD. SMITHFIELD, RI 02917 (401) 232-7230 FAX (401) 232-7290 22 June 2015 Mr. Leon Hall Sr. Plumbing & Gas Inspector Town of Yarmouth 1146 Route 28 South Yarmouth, MA 02664 Re: Yarmouth Housing Authority Yarmouth, MA Dear Mr. Hall: Find enclosed the following for the replacement of a combination boiler/water heater: 1) Plumbing Permit Application 2) Copy of liability certificate 3) Copy of licenses 4) Check for permit fees If you have any questions feel free to contact me. Vice Press MPL #PL Enc MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK G TYPE OR PRINT CLEARLY CITY I Yarmouth I MA DATE 22 June 2105 PERMIT # 11- 0 t y JOBSITE ADDRESS 1534 Winslow Drive Building #3 OWNER'S NAME I Yarmouth Housinq Authority OWNERADDRESS I TE 508-398-2920 FAX 508398-1930 OCCUPANCYTYPE COMMERCIAL® EDUCATIONAL® NEW:®. RENOVATION: ® REPLACEMENT: ED 8SMI 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 RESIDENTIAL PLANSSUBMITTED: YES© NO®+ 9 1 10 1 11 1 12 1 13 1 14 1 ha%n`a-ciurrentAabilltvinsurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES 0 NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND OWNER'S INSURANCE WAIVER: lam aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. or CHECK ONE ONLY: OWNER ® AGENT Cj are and that all plumbing work and installations performed under the permit issued for this applicat2vAin co liar e�jth Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. rlPLUMBER-GASFITTER NAME Anthon Centrella LICENSE # SIGNATURE MP MGF ® JP ® JGF ❑ LPG[ ® CORPORATION D# 2998 PARTNERSHIP #� LLC ®#[ COMPANY NAME:j CAM HVAC 8 Construction ADDRESS 1130 North Gate Way CITY Winchester STATE®ZIP 01890 TEL 5085058601 FAX 4012327290 CELL 5085058601 EMAILI tcentrellaa@camhvac.com �-2� -77Y-(-Oyv-S3i5 DIVISION OF PROFESSIONAL LI SEHIAI 0, �, �� �- IFT"- DIVISION OF DIVISION OF PPOFESSIONAL LICENSURE CAMHVAC-01 KESTANO f 11.. o CERTIFICATE OF LIABILITY INSURANCE `'� DAT/2212015 6/22/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endomement(s). PRODUCER Rogers & Gray Insurance Agency, Inc. 434 Rte 134INC,No South Dennis, MA 02660 CONTACT NAME: Kelly Estano, AAI, CISR PHONE FAx EA), AIC N.: (877) 816-2156 E-MAIL kesidno/� r0 ers ra ADDRESS: l_. 9 9 yCOm INSURER(S) AFFORDING COVERAGE NAIC# INSURER A: EMC INSURANCE COMPANY INSURED INSURER B:ARROW MUTUAL INSURERC:GREAT AMERICAN INSURANCE COMPANY Cam HVAC & Construction Inc INSURER D: 116 Lydia Ann Rd Smithfield, RI 02917 INSURER E INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE POLICY NUMBER POLICY EFF MWDDTYYYY POLICY EXP MMID IYYYY1 LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR X'C'U SDI-67.32 ---15 08102/2014 08/0212015 EACH OCCURRENCE $ 1,000,00 PREMISES Ea occurrence $ 300,00 X MED EXP(My one person) $ 5,00 X Contactual Liability PERSONAL&ADV INJURY S 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER. POLICY F JECOT LOC GENERAL AGGREGATE $ 2,000,00 PRODUCES-COMP/OPAGG S 2,000,00 EBL AGGREGATE $ 2,000,00 OTHER A AUTOMOBILE LUIBIDTY AUTO SE1-67-32•--15 08/02/2014 08102/2015 COMBINEDSINGLE LIMIT Ea amtlent tANY $ 1,000,00 BODILY INJURY(Perperson) $ ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS I BODILY INJURY (Per ( ) $ PROPERTY DAMAGE Per awdenf $ $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,00 AGGREGATE $ 5,000,00 A EXCESS LIAB CLAIMS -MADE 5JI-67-32 08102/2014 08/0212015 DED I X I RETENTION$ 0 $ B WORKERS COMPENSATION AND EMPLOYERTLIABIDTY YIN ANY OFFICEOPRIE ERIEXCLUERIE ECUTNE FRINIA (Mandeory in NH) If yes, descnbe un Jer DE SCRIPTIONOFOPERATIONSbelm 1766A 08/0212014 08/0212015 PER OTH- X STATUTE ER EL EACH ACCIDENT $ 1,000,00 EL DISEASE - EA EMPLOYEE $ 1,000,00 EL DISEASE -POLICY LIMIT $ 1,000,00 C Excess Umbrella SBE 0993821 00 08/02/2014 08/02/2015 Excess Limit 5,000,00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks RImdule, may be attacked a more space is required) Yarmouth Housing Authority is included as Additional Insured for General Liability and Excess (Umbrella) Liability, for ongoing and completed operations on a primary and noncontributory basis as required by a signed Written contract or agreement with the Named Insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Yarmouth Housing Authority THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 534 Winslow Gray Road ACCORDANCE WITH THE POLICY PROVISIONS. Yarmouth, MA 02664 AUTHORRED REPRESENTATIVE � G / ACORD 25 (2014/01) ©1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ea" W'v V.Po4. C'. & ev`tdtractiv" 9sac. 116 LYDIA ANN RD. SMITHFIELD, RI 02917 (401) 232-7230 FAX (401) 232-7290 22 June 2015 Mr. Leon Hall Sr. Plumbing & Gas Inspector Town of Yarmouth 1146 Route 28 South Yarmouth, MA 02664 Re: Yarmouth Housing Authority Yarmouth, MA Dear Mr. Hall: Find enclosed the following for the replacement of a combination boiler/water heater: 1) Gas Permit Application 2) Copy of liability certificate 3) Copy of licenses 4) Check for permit fees If you have any questions feel free to contact me. MPL #PL 15380-M Enc MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YA-/ MA DATE. L PERMIT # /�' a9A a2 5MS /fiN'�Ot JOBSITE ADDRESS E� 37 7UIA516W 6yl y VrQ OWNER'S NAME &A G " , r' / POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL RFA PRINT CLEARLY —/ NEW: ❑ RENOVATION: L/ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES 7 FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL W TI WT WATE; PIPINMal OTHER i i INSURANCE COVERAGE: I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY M OTHER TYPE OF INDEMNITY ❑ BOND ❑ 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 signature on this permit application waives this requirement. CHECKONEONLY: OW ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT 1,1,71 I hereby certify that all of the details and information I have submitted or entered regarding this application are true and r t to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complian it 11 P nt vision of th Massachusetts State Plumbing Code and Chapter 142 of the General Laws. LICENSE /? SI U PLUMBER'S NAMESt� MP [R/ JP CORPORATION R//#0?//0Z PARTNERSHIP ❑ # L C ❑ # / COMPANY NAME. UIVA/ P 4i l.�fllrttt/LtJJ• .�� 1 y�Y ADDRESS dtS l % 7-� CITY :2-f/-0 &�W� STATE l ZIP do-30-3 TEL FAX g?,� 5?(-1) awZL CELL 50� `1 �%lU EMAIL LP ROUGH PLUMBING INSPECTION NOTES I BELOW FOR OFFICE USE ONLY Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT # PLAN REVIEW NOTES FINAL INSPECTION NOTES /if2 fOt 011 J- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY YGnVKv lA MA DATE, 77 PERMIT# JOBSITE ADDRESS r tJ OWNER'S NAME POWNERADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL L PRINT CLEARLY / NEW: ❑ RENOVATION: R REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES 7 FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK AL LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET U ASHIN ILA I WATER HEATER Lt WER PIPING i OTHER BL'ILU.NG -PA TMENT ay INSURANCE COVERAGE: I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [D OTHER TYPE OF INDEMNITY ❑ BOND ❑ 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 signature on this permit application waives this requirement. CHECK ONE ONLY: OWN ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and 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 I Pertineytpre ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _ PLUMBER' NAMEK' Za'41"L)S' A E �LICEN�S�E#�d�/�� MP 7P ❑ CORPORATION � 4, �l / 07- PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME S61-VI IC ADDRESS � 6 � 03':h< % 9'Z ^� " " CITY�94KF& STATE <N ZIP ��� TEL �G' ZX�2W6 FAX,%OOy .7Dy ®�ql CELL/ /�L/ EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE; PERMIT # PLAN REVIEW NOTES FINAL INSPECTION NOTES / 2L�' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK IVCITY POWNERADDRESS TYPE OR PRINT CLEARLY _�— PERMIT#!!Z �JOBSITEADDRESS7A///AJrwr%4 1".Q OWNER'SNAME C Us C lG TEL FAX OCCUPANCY TYPE COMME IAL El EDUCATIONAL ❑ RESIDENTIAL [� NEW: ❑ RENOVATION: REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES-1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHIN WArEjhHFMTF&AkLTYPa WA E OT ER i TMENT ay _ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO ❑ IF YOU CHECKED YES, PLEASE INDICAT,E�THE 11 OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ly/ OTHER TYPE OF INDEMNITY ❑ BOND ❑ 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 signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and r e to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliant t II Pertine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _ PLUMBER' NAME l'.v �- �G�� t r' LICENSE77# I�f� RE MP PLUMBER ❑ CORPORA I N ® # %�p� PARTNERSHIP ❑ # LLC ❑p # COMPANY NAME e Q W ADDRESSU l�/767_S / < TAG -7 CITY �✓?Jz / STATE LZIP !/ 23D 3 SO& TEL :32 6 1 l74 .J FAX 0S 5*9a, 6 CELL -;j2jkEV 45,l EMAIL ROUGH PLUMBING INSPECTION NOTES I BELOW FOR OFFICE USE ONLY Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT PLAN REVIEW NOTES FINAL INSPECTION NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK POWNERADDRESS TYPE OR PRINT CLEARLY CITYGvry✓��; MA HATE; a PERMIT# JOBSITE ADDRESS (VYv r J2 OWNER'S NAME T G C Y� TEL FAX OCCUPANCY TYPE COMME IAL ❑ EDUCATIONAL El RESIDENTIAL NEW: ❑ RENOVATION: REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER it FLOOR I AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL - - 5}W If TI TE -R TE PIPING 0 HE ,11 RTMENT !ey _ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ❑ NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER TYPE OF INDEMNITY ❑ BOND ❑ 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 signature on this permit application waives this requirement. CHECK ONE ONLY: 0 R [I AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true a to to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complia all Perfinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME S—ftAAVct 2 -A 't S LICENSE # I bq l A E MP JP ❑ CORPORATII_OIN/ L7 -��1# ,;;?�- PARTNERSHIP ❑ # l�LLC ❑ # COMPANY NAME 1�ryPl/{ Lc n� IBC Ylwf ADDRESS'2 0- dA 1 9 Z5 ` > CITY � mow" STATE S ZIP O2_1 �d TEL j lJ ? FAX�'YO UOw ( CELL ✓c e EMAIL S ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT # PLAN REVIEW NOTES FINAL INSPECTION NOTES r P« ey-t MASSACHUSETT.S}U�NIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY yfni-WIAuI to MA DATE. j PERMIT# A-/210-6510'6-�'e • JOBSITE ADDRESS J 3� i ZAJt�+aS [a J �u yr9 OWNER'S NAME c 3 + POWNER ADDRESSt TEL FAX TYPE OR OCCUPANCY TYPE COMMAL ❑ EDUCATIONAL ❑ RESIDENTIAL OMM PRINT CLEARLY NEW: ❑ RENOVATION: REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM 11 DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WA H N WATER WA TRIPPING OTI ER BUILDING O RTMENJ By INSURANCE COVERAGE: / I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Q NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY L7 OTHER TYPE OF INDEMNITY ❑ BOND ❑ 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 signature on this permit application waives this requirement. CHECK ONE ONLY: OW ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true a cu a to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compl!Vp w3Wall Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME`5VVV{-z`A00"J IU'9A,7 I NA RE /'LICENSE# MP � JP ❑ CORPORATION 92 # A I L PARTNERSHIP ❑ # C ❑ # COMPANY NAMEV.t-�Seu-vl�s k1� in�r�� ADDRESS - U- 'u b?X L11 J CITY � Jot ic/ STATE �, ZIP 47,3 D 3 TEL 5j* 37 53 ���0 FAX ,5� S8U 041 CELL JQSS' 'yi1y EMAIL Lklf ROUGH PLUMBING INSPECTION NOTES I BELOW FOR OFFICE USE ONLY Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT # PLAN REVIEW NOTES PINAL INSPECTION NOTES i -c PLC O2 L4,v O M 04,NW LTH OF'M1riSSliGFil3SEi ''LUhic3"crams`:" GASF:jTT-�ia '.. ?S T S SS"E cQLLOWING`'L`'sF`E>;t`� = -tr23 _ 0