HomeMy WebLinkAboutBLDP-19-001388 Rory p&2 ?-I( •
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• MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
•
dal_ CITY/TOWN SDU�h 7if77c16/7�G MA DATE Fight • PERMIT# 01/9-'
JOBSITE ADDRESS 2 2 'Br .dd'fC 37 OWNER'S NAME /flim w /2a--Ac s(
OWNER ADDRESS TEL FAX r
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL Ly
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES 0 NO El
FIXTURES 1 FLOOR-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 1
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR 1 AREA DRAIN
INTERCEPTOR(INTERIOR) •
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL ` F C E V F D
SERVICEI MOP SINK /,-k13Q ^+")
TOILET lig - Z od .
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES I I LIUIL\)INGUEPAFTMENT
WATER PIPING t by
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
THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY It/ OTHER TYPE OF INDEMNITY 0 BOND ❑
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
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
3and
d 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 compl• all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,/1J.{
PLUMBER'S NAME J3CrA.! AI) 6 rJ LICENSE# 11977 SIGNATURE
MP L� JP❑ CORPORATIONit PARTNERSHIP 0# LLC❑#
COMPANY NAME CAPE cI n/va6.ns 1 Remy x'-ADDRESS AO, 43&( 51 ZS
CITY SD✓74 Dc4'.4,/1 STATE/11.4- ZIP 6 2 G G O TEL SF - JSd' - Ztzj
FAX CELL EMAIL
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SCS. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY S'nrf7x1 q.a.tncold MA DATE q/G /it PERMIT# /le.-2
JOBSITE ADDRESS 21. 3/'nofdocc Sr OWNER'S NAME st7i..' /t..zu
G OWNER ADDRESS TEL FAX m
TYPPEEVOR OCCUPANCY TYPE COMMERCIAL El • EDUCATIONAL 0 RESIDENTIAL a.de
PIU
CLEARLY NEW 0 RENOVATION: ❑ REPLACEMENT: 2 PLANS SUBMITTED: YES 0 NO t'
APPLIANCES 7 FLOORS-. BSM 1 2 3 4 5 8 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 r E C E I V E '' '
ROOM/SPACE HEATER • { nr ,213
ROOF TOP UNIT !I '-' ?o1?
TEST t
UNIT HEATER
UNVENTED ROOM HEATER • JILU rtV oErA trn/�,tT
WATER HEATER I ,
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142 YES 13140
❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY INSURANCE POLICY 2 OTHER TYPE INDEMNITY 0 BOND ❑
OWNER'S INSURANCE WAIVER:I=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.
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#11977 SIGNATURE
MP I s MGF❑ JF❑ JGF 0 LPG'0 CORPORATION LTJ A PARTNERSHIP 0# LLC 0#
COMPANY NAME Cage CCJ PIumtan( a-N7f '& ADDRESS ?o• /ifoX 421
CITY S )Painf' STATE"Ms ZIP 02(66 TEL Sot- J1F - 2LtP
FAX CELL EMAIL
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