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HomeMy WebLinkAboutBLDP-19-001487 A9f►P : PAR eel : gs„ MASSACHUSETTS UNIFORM'APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK .n! Cir ._.... __. .._\/x Qt'YJ O_( J1 • 1 MA DATE I oZ I PERMIT# /I�/C J`21 ti; I I1� OWNEIr�n kon^YUr0 JOBSITE ADDRESS �Q _at;u,,-1. �� P OWNER ADDRESS ( TE 5n 1.- 4 65 (FAX TYPE OR OCCUPANCY TYPE COMMERCIAL C:3 EDUCATIONAL 0 RESIDE PRINT �.,y CLEARLY NEW:E] RENOVATION:EI REPLACEMENT:I_°! PLANS SUBMITTED: YES 0 NO❑ FIXTURES 7 FLOOR-. IBSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 CROSS TED CONNECTIONL DEVICE � it i�'�� Inn BATHTUB 1 DEDICATED SPECIAL WASTE SYSTEM an DEDICATED GAS/OIL/SAND SYSTEM aliiimituani DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER aE DRINKING FOUNTAIN MR at ilS MIMI P',M S,S inn i a FLOORlFOOD IARfJtDRAIN • a I "mu...M ' IC I .I '1 ._1 _ SERVICE I MOP SINK ,: , „,--11- il - ' .- TOILET y URINAL WASHING MACHINE CONNECTION '' WATER HEATER ALL TYPES lip WATER PIPING , OTHER Imo, 1 BNMIPIIIIIIIIKEIRMINKWIIRMIRWIMAtillila r j • INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 20-NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY I_":! OTHER TYPE OF INDEMNITY❑ 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 ❑ 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 mr^,X"^nca with e0)iertlgnafbpro• bn of the Massachusetts State Plumbing Code and Chapterap142 of the General taws. _ L[/��,/y/�J PLUMBER'S NAME Kest) r inva kP 1LICENSE# (IboLO - SIGNATURE MP R:1 JP© CORPORATION yi#AO.C, IPARTNERSHIPED# Li-CED J COMPANY NAME 4U,'n � MCA; Pr* P, =n r•, (ADDRESS tI (,adrr Avg I CITY W. ` orSTATE MI ZIPI 01g3 TEL (5o ) i < V(E FAX 4of"r'io_Btgcl CELL�S��o1)St4.37)41 EMAIL I ' Em L pit)m b 0 Com fets4 r ? eA • //' //�� SEP 122018 • t�l� BUILir;NT , O BY �� - . i • .. .. L\. C.._ t` kl , ‘;.' Ji _ _ , . • ... _ ' • _4 ,r :, X1.1( �JAP /0i9R c e./ s•-• , * g.• er, ...MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK �L- CITY,Tovarh ofof \/A0WICMA DATE q I PERMIT it &JO-R-0M n JOBSITEADDRESS! p1-I l ,i rU,,4 Pt) . 1OWNma'SNAME I De)r;C lin trrCrr 1 GOWNER ADDRESS TE{r -n OR r� i-09 PRINTTYPE R OCCUPANCY TYPE COMMERCIALS ,,E/DUCATIONAL0 1 RESIDENi1AL1' CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:134 PLANS SUBMI 1 t tU: YES 0 NOD APPLIANCES 1 FLOORS-4 Rai 1 2 3 4 5 6 7 • I 8 9 10 ' 11 12 13 14 BOILER - �M� �� :�n� BOOSTER liffi7ia *SISf _S� ;St CONVERSION BURNER 1 � �,asaa am.mak_s_i COOK STOVE • __ M MiJ__ DIRECT.VENTHEATER ____f � .1� 11 ,�S. DRYER FIREPLACE __ : I _ FRYOLATeR RIRNACE en. • GENERnnattat en ATOR = 1 fr-GRILLE MSM ie , . e T!1'�"` ... arfit • INFRARED HEATER S1• —,1• Mt 1111.a01111t WSW WE=SS. - LABORATORY COCKS —fl fl——pf LC11_,}W6T=71. 1,11: • 1 '�•n,j• [z1 j MAKEUP AIR UNIT `- ° • , OVEN' POOL HEATER ' nt Mat SiditWL.W.Cal&lailIan ROOM/SPACE HEATER 1St 1=1•�'- =;=.1=:=r7:6;4 >_._;_ ROOFTOP UNIT • .l■�runC> _ r r '� ' ''! __ TEST UNIT IT HEATER Ratintainisann UNH : T ROOM HEATER OTHER INSURANCE COVERAGE I have a current liability Insurance policy or Ds substantial equivalent which meets the requirements of MGL Ch.142 YES U NO 0 IIF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE,,.._/ BY CHECKING TIE;APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY Cl • BOND Q OWNER'S INSURANCE WAIVElt I am aware that the licensee does not have the ktsurance 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 Q AGENT Q SIGNATURE OF OWNER OR AGENT I hereby tartly that all of the details and kdarnalion I have submitted or entered regarding this application am true and ecnrrata b best of my imowledge and that all plumbing wok and Installations perfumed under the permit ksued for this applicator will be In compliance wl�hr t provision of the Massadwsets State Plumbing Cede and Chapter 142 of the General Laws //`lrJ/L,SF� PL.UMBERc,ASFTfTER NAME 1&;n 99 l G2 r:fie. (LICENSE - 1169 0 ` - • SIGNATURE - MP VI MGF© JP D JGF Q11 LPG'❑ CORPORATION a 80 C. PARTNERSHIP) ,LLC a COMPANY NAME'Vo :m r:ch Plum+N�F .41cIADDRESSJ II 01-y1,44 P4 G c t ! v C D . I • CITY III. Yrrrrnno+lh • 1 STATE MaZIP1 OP 673 1113.1 4560 *- 4 556 - FAX 0Y)7ao-571/510ELLI (EMNLJ - CFP 12 2018 1 • • ^ I� ENT a• SU! 1 ., r I, ' lI.lit r • 0 IL -.. . r r \• .: . • n • •