BLDP-19-001464 d_ MASSACHUSETTS UNIFFORM,/APPLICATION FOR A PERMIT TO PERFORM PLUMBINGQ � WORK '/
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CITY In�•-r, rt.-f( 613...,/A MA DATE 'i1//a PERMIT#['I�•!�/'%/ 1 y�2 i
JOB ADDRESS bo cry- • /(�/
/ Gi��• Rd OWNER'S NAME fte-ro c n 1 adkile
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL[3.--'''
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES❑ NO 0
FIXTURES 7 FLOOR-. BSM 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(INTERIOR)
KITCHEN SINK
LAVATORY
1 ROOF DRAIN
j SHOWER STALL • _
! SERVICE/MOP SINK •
I TOILET
URINAL
, WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES I _
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MG V .. ■
IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELO IF D
LIABILITY INSURANCE POLICY [V' ' OTHERTYPE OF INDEMNITY 0 BOND 0 SEP 11 2018
OWNER'S INSURANCE WAVER:I am aware that the licensee does not have the insurance coverage requi ed ,a.ter 142 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement a I:DI�-e : •he ,.
T CHECK ONE ONLY: OWNER ❑—AGEGENNT ■
SIGNATURE OF OWNER OR AGENT
1.1-1 I hereby certiythat 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 income all Pertinent rovisio e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws,
PLUMBERS NAME 6,ctI /�.-r.seirk LICENSE# f6,syq .
SIGNATURE
MPV JP 0 CORPORATION 0 it PARTNERSHIP❑.# LLC 0#
COMPANY NAME 76.n,&-sc. - Me,..L.S ADDRESS X03 C/4,.-cn SI
CITY �N•enno, tin fl- STATE e^4 ZIP pZZ 75— TEL 37R-Ctz2- -firyof
FAX CELL EMAIL L
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-7011 1724-j;- _
•
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY Y/--1 ors. di/ S 04.45j MA DATE /«/l PERMIT#/x��i' -6161/7611(
JOBSITE ADDRESS 6 B Cod,f; ' }�d1— r r/ OWNER'S NAME At ,oi,q J Qs�e /k f fC
OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT /
CLEARLY NEW:❑ RENOVATION: 0 REPLACEMENT:Ly' PLANS SUBMITTED: YES 0 NO 0
APPLIANCES 7 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 --I
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS •
MAKEUP AIR UNIT
OVEN 1
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
TEST • . . ..._ .._... .. . •--•• __ _._
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER 4
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MR..E1.Q2E VV y
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX B EU
UABIUTY INSURANCE POLICY � OTHER TYPE INDEMNITY 0 ag3Dlm 2018
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage rc ,t i g•
Massachusetts General Laws,arid that my signature on this permit application waives this requirement.BY. Of `;,ni - ' A '
•
CHECK ONE ONLY: OWNER 0 AGENT 0
SIGNATURE OF OWNER OR AGENT
TIS 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 per ii 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.
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PLUMBER-GASFITTERNAME g' J 7M4$4,h5" LICENSE# Ibsgy SIGNATURE
MP er GF 0 JP❑ JGF❑ LPGI 0 CORPORATION❑# PARTNERSHIP❑# LLC❑#
COMPANY NAME /on,, ,/j,- ft— 3 ADDRESS /0 7 IA re>, ,
CITY i. a, ti, re'," STATE /"/a ZIP 07-6 7r TEL 5$- 9z?-/eo/
FAX CELL EMAIL &1(261----
ROUGH GAS INSPECTION NOTES. . THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No /^/ /
THIS APPLICATION SERVES AS THE PERMIT 0 0 / -4111-49C°.'
/7�L' -49C°- lad 9
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FEE: $ PERMIT R G jJ / T
PLAN REVIEW NOTES
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