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HomeMy WebLinkAboutBLDP-19-001474 • 4 ' MASSACHUSETTSAUNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK Lr CITY f [{r ybd L.'I� MA DATE Q' IZ ' S PERMIT It /91-1)P79-00I /u 79 JOBSITEADDRESS 9tv Suck Cr-SLu1A [a kur} at OWNER'S NAME cC4t6 JIv1G CLIA` POWNER ADDRESS 5 AIM e.-- TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 9 PRINT — / CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:LiPLANS SUBMITTED: YES 0 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 GASIOIUSAND 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 I TOILET , URINAL WASHING MACHINE CONNECTION T WATER HEATER ALL TYPES ! WATER PIPING j OTHER INSURANCE COVERAGE: © !� c I have a current liability insurance policy or its substantial equivalent which meets the requirements of M CLQ thNC 4YYE ONES IF YOU CHECKED YES,PLEASE INDICATE THETYP E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELmW SEP 12 2018 LIABILITY INSURANCE POUCY L OTHER TYPE OF INDEMNITY 0 BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage re vii W ' :f"'' 1 TinfirjO 1 Massachusetts General Laws,and that my signature on this permit application waives this requirement CHECK ONE ONLY: OWNER GENT ❑ SIGNATURE OF OWNER OR AGENT L:1 I hereby certify that all of the details and Information I have submitted or entered regarding this application are true and accurate to the bes y(knowledge and that all plumbing work and Installations performed under the permit issued for this application will be In comp' rice with all Pertinent�provision� of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ��i) i, PLUMBER'S NAME 1X1/4--tA (}J t \ et art PARTNERSHIP )5 ) q �SILGNAATUURRELf�� MP(i� JP 0 p CORPORATION L7 rt PARTNERSHIP 0# LLC❑# COMPANY NAME J t,.v"Pr�f C c U-lknlcltin i ADDRESS '771/ uik,L ✓ GYc.c ( CITY S r Vbrr v IA' STATE )0t-k ZIP 6'2-4 a y TEL CaSe 23 7 `i5 c .1 FAX CELL j 4M -- EMAIL O1 I 1/ 213 c)fO .v40/ 24i//),Z ,1 r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY rkN 4vt0 La MA DATE q - ).2- 17. PERMIT# &ppi9-- 0/979 JOBSITE ADDRESS 340 L 4r k err(toA U N i 3- 18a-OIMJER'S NAME Scram}kinaCC. GOWNER ADDRESS 5C9^1 p, e TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL[� PRINT �/ CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:L7 PLANS SUBMITTED: YES 0 NO❑ APPLIANCES? FLOORS-• SSM 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 f OTHER INSURANCE COVERAGE I have a current liability Insurance policy or its substantial equivalent which meets the requirementsef-MCL Ch.142 YES h0 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF CO7GE BY CHECKING THE APPROPRIATE BOX Low C E I V E LIABIUTY INSURANCE POLICY OTHER TYPE INDEMNITY 0 sEtiO5[A}8 • OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage rec uired by Chapter 142 of\he Massachusetts General Laws,and that my signature on this permit application waives this requiremeatui i rrw DE PA RIM NTec 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 knowledge and that WI plumbing work and installations performed under the permit Issued for this application will be in compli nce with a Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 44/67/ PLUMBS -GASFITTER NAME -MI Ye4Q I e)' CENSE# S GNATURE 2` MP LJ MGF 0 JP 0 JGF❑ LPGI 0 CORPORATION # , ,�7 PARTNERSHIP 0# LLC 0# COMPANY NAME T u%re kc V \ULLA aOM L ADDRESS Lf 7 N CEJ ) US J o ur r-w1 , Qat CITY 3 t PA V On o (a*tn STATE PA ZIP 67 61, ti TEL 3.—C* -)377357(C1 FAX CELL_4 &INN EMAIL � � • • BOUGH GAS INSPECTION NOTES-- THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ 0 /^}�- / FEE: $ PERMIT i6 fZ�' ' ✓ #/ ' KLAN REVIEW NOTES diCv " ? / / . •