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HomeMy WebLinkAboutBLDP-18-004111___j MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK P TYPE OR PRINT CLEARLY CITY \rr%� MA DATE CTT� PERMIT#'r�'O� l JOBSITE ADDRESS OWNER'S NAME / -- OWNERADDRESS TEL III OCCUPANCYTYPE COMMERCIAL EDUCATIONAL M RESIDENTIAL[] NEW. El RENOVATION:© REPLACEMENT: PLANS SUBMITTED: YESM NOM 12 13 14 FIXTURES 1 FLOOR-+ BSM 1 2 3 4 6 6 7 8I�Ikl. BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEMI1. DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liabilityinsurance policy or Its substantial equivalentwhich meets the requirements of MGL Ch.142. YES M u0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRATE BOX BELOW LIABILITY INSURANCE POLICY O OTHER TYPE OF INDEMNITYM BONDM OWNER'S INSURANCE WAIVER: I am aware that the Hearses 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 requiremenL CHECK ONE ONLY: OWNER E] AGENT M SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information t have submitted or entered regarding this application are true and accurate to ate best c my knowledge and that all plumbing work and installations performed under the permit issued for this application W91 be in mpliance with all Pertinent prrnisi of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I Craig Bishop LICENSE # 15101 SIGNATURE MPQ JPM CORPORATIONM#9PARTNERSHiPFJ#[=LLCE1#C� COMPANY NAME I High Efficiency—I ADDRESS 1378 Route 130 CITY Sandwich 1 STATE = ZIP 02563 _ _ _ _ , TEL 508 825-3695 FAX CELLEMAILadmin hi h-efficien llc.com n )/ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK —CITY �._...._--_ , PERMIT#MA DATE JOBSITEADDRESS at.a 4 OWNER'S NAME GOWNERADDRESS yTE Q(} AX PRINT OCCUPANCYTYPE COMMERCIAL©] EDUCATIONAL; RESIDENTIAL] CLEARLY NEW:E j RENOVATION:'] REPLACEMENT: : PLANS SUBMITTED: YESIEj NO�jI APPLIANCES 1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER_.....'.__.__....I_...._LL.._.-. kl_.__J:!_.._. — CONVERSION BURNER__D COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR L..._J,I__. �_ _ — I— I��--'; FURNACE GENERATOR�L_.__il- GRILLE— INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT .. _i` G[_._..._J _I:-_—+ --.-' OVEN I _-._n POOL HEATER _ — —= _ _ ROOM! SPACE HEATER ROOFTOPUNIT__— TEST-- — UNIT HEATER I ' r= UNVENTED ROOM HEATER WATER HEATER OTHER - _— -- — -- --__..INSURANCE COVERAGE 1 have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E] OTHER TYPE INDEMNITY Ej 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 E2 AGENT SIGNATURE OFOWNERORAGENT I hereby certify that 88 of the details and information 1 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME C2i Bisho { LICENSE #;15101 SIGNATURE MPO MGF F� JPE] i! JGF E] LPG[ CORPORATION 0#� j PARTNERSHIP fj,�.'' # LLC # COMPANY NAME: High Efficiency h ADDRESS 378 route 130 1' CITY Sandwich STATE Ma J ZIP I02563 TEL —� FAX# — -,_ CF11__ ,EMAIL adminhefficiencyllc.com,,,,,� n )/ At