HomeMy WebLinkAboutP-19-733 • g"j, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORKin
a1li CITY/TOWN Sov71 Yhtnni-7�C MA DATE Fhb/ PERMIT#Prn-C O
741
JOBSITEADDRESS 40 6 tCc,c Clrclt OWNER'S NAME Dc-411 No1wr..d.vnr
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL[' f 10'00
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES 0 NO F/
FIXTURES 7 FLOOR-. BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 1
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOILISAND 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
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER Bali cc alai d (
INSURANCE COVERAGE: RECEI '/ F
I have a current liability insurance policy or its substantial equivalent which meets the requirements of G-Ch-142.-YES C•/-`NO
IF YOU CHECKED YES,PLEASE INDICATE
THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BE 0 AUG/7 2018 ari
LIABILITY INSURANCE POLICY I�Q OTHER TYPE OF INDEMNITY 0 BOND CM... 9 .
BUILDING DEPARTMENT
OWNER'S INSURANCE WAIVER:l am aware that the licensee does not have the insurance coverage re uired 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 ❑
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 accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will beincompliange • all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 47A;7.1
PLUMBER'S NAME '8rrn.✓ 54,Gre LICENSE# IIS77 SIGNATURE
• MP[y JP 0 CORPORATION [3'9r` PARTNERSHIP❑# LLC 0#
COMPANY NAME CANG tad PIM INC. ADDRESS PDQ /1ti.7‘ 725
CITY 5. ttNNIJ STATEflI- ZIP 02666 TEL 574) 3572
FAX CELL EMAIL
J7/40 -79y-7
)--zo 979/
•
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
' CITY Youth /42/nb. -z( MA DATE H7h? PERMIT# / b-N—t't7t#!'
JOBSITE ADDRESS ti# 6 cl.rrr f C,r r l r OWNER'S NAME DeA,i/ I/O F.d 0-91".
G
ti',-
G OWNER ADDRESS TEL • FAX r
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 • EDUCATIONAL 0 RESIDENTIAL[V
PRINT
CLEARLY NEW 1217 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO re-
APPLIANCES 7 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 • 13
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR • •
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS •
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER •
ROOF TOP UNIT
TEST •
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
•
•
INSURANCE COVERAGE LE C E I i lEI have a current liability Insurance policy or its substantial equivalent which meets the requirements of MG —YES NO
IIFYOUCHECKEDYES,PLEASEINDICATETHETYPEOFCOVVERRAGEBYCHECKINGTHEAPPROPRIATEBOXBELOiUG 07 20j8
LIABIUTY INSURANCE POLICY h� OTHER TYPE INDEMNITY ❑ n ❑ C-C.1'ING DEPAR rMENT
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage requirpter_142 of the_
Massachusetts General Laws,and that my signature on this permit application waives this requirement. i 4cYJ
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 true and accurate to the best of my knowledg
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 LICENSE#11177 SIGNATURE
•
MP 1E/MGF 0 JP❑ JGF❑ -LPG 0 CORPORATION Lr# PARTNERSHIP 0# LLC 0#
COMPANY NAME Calot Cod Ft um d,.,' +1177 XfL. ADDRESS 1'A• /SOX 4 21
CITY S Mai/if STATE 1934- ZIP•1i 2 6( n TEL Sot- 39F - Z Z z
FAX CELL • EMAIL
poff- 614. alc 643 Olt
Zig 117 g (Aez- sthr