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Home My WebLink AboutBLDP-18-006660 Jt. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 'Q==E' � / -a' " CITY . 1 i/ MA ATE _�✓��[J�' P IT# /1-Gd ll�i(CO JOBSITE ADDRESS 1/ poll �1 OWNER'S NAME D % i P OWNER ADDRESS TEL ag-69/^74% FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL PRINT / CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:I� PLANS SUBMITTED: YES 0 NO L FIXTURES 7 FLOOR-. ESM 1 2 3 4 5 6 7 6 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 t DISHWASHER cul DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN \V - 01 _ INTERCEPTOR(INTERIOR) 1 KITCHEN SINK ROOF LAVATORY4 L ( ROOF DRAIN IN d } C SHOWER STALL -0 . �I SERVICE/MOP SINK .( TOILET _ Mgr 23 261E URINAL / WASHING MACHINE CONNECTION Bt N 'ARTM_ VOA n WATER HEATER ALL TYPES ( 1 13'. !!1111 --4__ \CS WATER PIPING OTHER MI I. INSURANCE 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 TH TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 4 UABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the i Massachusetts General Laws,and that my signature on this permit apelication waives this requirement. it CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT LLI I hereby certify that all of the details and Information I have submitted or entered regarding this application are 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 lian'- w�y, all Pertinent provision of the Massachusetts State Plumbing Code and C pter 142 of the General Laws. �y /.14 PLUMBER'S NAME by. ?)VII(C LICENSE#1/1112 . � w • SIGNATURE MP eJ JP❑ CORPOOFWION 0# PARTNERSHIP�r❑.#/ LLC 0# COMPANY NAME /4/1� Y �/fJS( & �7T! ADDRESS n I lilt I l ff I� (iii CITY 4a-u fLL STATE !l?/• _ ZIP 192-bet TEL�V� tilr� FAX CELL EMAIL J l gg. ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ 0 ��j� yp FEE: $ PERMIT# g �2V17,`—(Y CJCi PLAN REVIEW NOTES Odi MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK it;'. iir c- CITY L140uo14 pelt MA DATE 7,l /8 PEWIT# n /P'•cn6149 JOBSITE ADDRESS l/0 ham (01(74 OWNER'S NAME l OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 2------ PRINT CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:EIv PLANS SUBMITTED: YES 0 NO IV-- APPLIANCES /APPLIANCES 2 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE A FOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS I R, E C E I y E D MAKEUP AIR UNIT t OVEN ! 1 k POOL HEATER • MAY 2 R 701E ' ROOM/SPACE HEATER j (�(f ROOF TOP UNIT TEST g. DE,n`aF H‘ Ts. UNIT HEATER UNVENTED ROOM HEATER WATER HEATER / OTHER Iiii` INSURANCE COVERAGE I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES al 0 Nil I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW J LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND 0 SZ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Z Massachusetts General Laws,and that my signature on this permit application waives this requirement ill CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are truarSd 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 comp (ce wi all ertinent provision of the Massachusetts State Plumbing C d Ch ter 142 offtth/e General Laws. PLUMBER-GASFITTERNAME I b 6 - LICENSE#I/1/7 SIGNATURE MP LJ✓ MGF 0 JP 0 JGF❑ LPGI❑ CCORPORATION 0# PARTNER HIP 0# LLC 0# COMPANY NAME y(yV4I_- C TI ADDRESS C? iwiiis /V — CTY ehtk1A & STATEA/4z_ ZIP 0.2 1,7 TELQ i G52/ 2711 FAX CELL EMAIL / /f ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ 0 FEE: $ PERMIT# FPn49-( v 4-5 PLAN REVIEW NOTES o" _ tie A