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Home My WebLink AboutBLDP-19-001328 perregfrunie j ' _ MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK J CITY 1/4/%4000 MAIA" / DATE y/ ( PERRMIT#1vPR/�'co/'9o�g JOBSITEADDRESS /�� l tQd fl/ ,c&Ll ` OWNER'S NAME /! J 04' OWNER ADDRESS Wi Yate TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL 12( PRINT CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:. PLANS SUBMITTED: YES 0 NO.e( FIXTURES 1 FLOOR-. BSN 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(IN I EKIOR) _ KITCHEN SINK LAVATORY ROOF DRAIN C r I SHOWER STALL ria-5 ! SERVICE I MOP SINK 1 i TOILET sP URINAL A 2 WASHING MACHINE CONNECTION 6rlu P.,, -r— WATER HEATER ALL TYPES WATER PIPING 1 OTHER 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 THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY 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 Massachusetts General Laws,and that my signature on this permit apQf'ication 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 be In compliance wi al Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4,11111, PLUMBER'S NAME 674fyn. LICENSE# OP IGNATURE MP 71 JP❑ .,/� CORPORATION 0# PARTNERSHIP 0# LLC 1# �f' / COMPANY NAME//,, elli�(/ /42/6// A, ADDRESSSS/0116,a CIC// '/✓� q n CITY�OI/7 / STATE'S ZIP x/61 TEL c04150 � 2775 FAX CELL EMAIL O/ LP )12 &12y(1 )'d MASSACHUSETTSSA ,IUNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK • rag, Egt CfTY yu"` s70, / �A DATE PE/RRIN/ITf/�I�J�ir—Cd JOBSITE ADDRESS //,�O a 6� OWNER'S NAME/- �L/ Ce04 GOMER ADDRESS 6/ rill TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL al PRLNT CLEar NEW:0 RENOVATION: 0 REPLACEMENT:IQ PLANS SUBMITTED: YES 0 NO 21 APPLIANCES1 FLOORS—. BSN 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 FLE J V € B— POOL HEATER ROOM SPACE HEATER ROOF TOP UNIT U q Zijfi TEST . .• . . . . . .. ... _ .. .. . . UNIT HEATER e IL, rr1 UNVENTED ROOM HEATER ey i1_ 44 P WATER HEATER J OTHER r_ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES 0 NO 0 I F YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY ❑ 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 ray signature on this permit application waives this requirement. 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 a urate to the best of my knowledge and that WI plumbing work and Installations performed under the permit Issued for this application will be In complian all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. '/ �� PLUMBER-GASFITTERNAMF�LZ/_ 4JL LICENSE# sez SIGNATURE /� / MP Oj MGF 0 JP 0 JGF LPG CORPORATION❑4 PARTNERSHIP❑# LLC m#�J.<?! COMPANY NAME& / 7a`v/t /P,ffGGb ADDRESS 44/ ITY (/ J C 4/ STATES ZIP a?el TEL sig-c07 /"‘ Gc " FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes , No THIS APPLICATION SERVES AS THE PERMIT 0 . 0 / 9n4/Lf 6,9 FEE: $ PERMIT# �� ./-{� PLAN REVIEW NOTES, CSP \ /' 9/5 /7? • J 2