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Home My WebLink AboutBLDP-18-002916 4 •r"t MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 1== , geA MA DATE !!I "1 2-017 PERMIT#pl/��/8—��b JOBSITE ADDRESS 6 V!��kv c4 PtpI OWNER'S NAME C f)^ o f /t'Gi vm OWNER ADDRESS T6 Vel ✓LA f2N TEL FAX (/ TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL®' PRINT CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:'4 PLANS SUBMITTED: YES 0 NO 0 FIXTURES 1 FLOOR-' BSIV 1 2 3 4 5 6 7 B 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 I MOP SINK ( TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES I WATER PIPING OTHER f 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 THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABILITY INSURANCE POLICY Cgl OTHERTYPEOF 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 f Massachusetts General Laws,and that my signature on this permit application waives this requirement CHECK ONE ONLY: OWNER ❑ AGENT 0 SIGNATURE OF OWNER OR AGENT Lk! 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 be In compliance wi II Perlin rovisio e Massachusetts State Plumbing Code and Chapter142 of the General Laws. PLUMBER'S NAME AheV'tv4 S• Alo 'Ccof/r,/ LICENSE#�Z 3 , vv SIGNATU MP'gn JP❑ CORPORATION #Y6ti PARTNERSHIP❑.# LLC❑# COMPANY NAME AG7rl ' r rit2T L7rafiu i—A ADDRESS 3% I3/mn.bevv/ iV Olt CITY W_ t ✓ .TATE /r l ft ZIP 0 2.6�I TELt'3`ng�a�7 ')e '7 FAX A 0 .61fy�gNay ¢� 16LL20 ♦ , , EMAIL as/1 Mcc4a '1 stet /&/jf/j.nv 64 . /y�0_RT .Ise ✓� lllrrr {1 ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 0 FEE: $ PERMIT I/ 7~-C (I/ e"/ PLAN REVIEW NOTES a MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK rauirn j k ktA DATE /l'IS /0!7 PERMIT# /p r "%�E--�� `� CITY Lt✓wick-1k 0 Ll� /iL-//�7��-d� / JOBSITE ADDRESS l y,rrlt/I✓al Re' OWNER'S NAME r,n G.�� GOWNER ADDRESS 9/6 V(kit inA� TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL, ] PRINT CLEARLY NEW:❑ RENOVATION: 0 REPLACEMENT:g PLANS SUBMITTED: YES 0 NO 0 APPLIANCES 1 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 _ 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 I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES VI NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY (gJ OTHER TYPE 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. J CHECK ONE ONLY: OWNER ❑ 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 knowledge `- and that all plumbing work and Installations performed under the permit Issued for this application will be In compliance wig..I Perti �; provision , the itMassachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME A h fa) S, Msg.& LICENSE P.BP3 SIGNATU MP® MGF 0 JP 0 JJ GF❑ LPG!❑ COR/PORATION,�]#3155 PARTNERSHIP 0 if LLC❑# •COMPANY NAME A , s, N . MA/r.4r1,Cat 1 Zi L ADDRESS 26 , Pd J�✓ CITY J3Y( v STATE )flo1 ZIP • ,-31 r EL lintt 117 r� FAX � V`~'CELL SIEMAIL rAShint G�i;�c ,'Lw incs /,lia1'r / NOV'1 �Of5 2617 l - (,{` 6EE Prrit nie011,060 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 0 FEE: $ PERMIT# F PLAN REVIEW NOTES 107C &vim 7/ir f