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HomeMy WebLinkAboutBLDP-15-006287 • grJ, MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK -1-10 CITY (A, MA DATE £ �R( IS— PERMIT#fr-OF`/!5'DCIZ 87 JOBSITEADDRESS 51 7 Trr+ ei r /2U OWNER'S NAME 'T D - T OWNER ADDRESS rids Sw Y6-4.4-.-f„" TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL(% EDUCATIONAL 0 RESIDENTIAL❑ PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: J PLANS SUBMITTED: YES 0 NO FIXTURES 1 FLOOR- 8SM 1 2 3 4 5 8 7 8 9 10 11 12 13 14 BATHTUB . CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN - • i rI� FOOD DISPOSER r R E+ C I / FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY -UN 9 )15 SODRAIN SHOWER STALL juiW NGL.EPAFTM T T SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES - WATER PIPING OTHER - • INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ra.--NTS❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW • LIABILITY INSURANCE POLICY Ifde 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 application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby candy that all of the detads and Information I have submitted or entered regarding this application are hue 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 coal.I nce 0.ti Pert nent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _ rr PLUMBER'S NAME LICENSE# 90( SIGNATURE MP[TV JP❑ CORPORATION Erri yoi& PARTNERSHIP❑# LLC❑# COMPANY NAME (-dr (4") fric1:c f ADDRESS .9 f f/-«n A c/�`/ CITY s CipM(nith STATE 1uPI ZIP OotGroy TEL ��i'1"7S�� 71`Zt FAX 5-0,9 ..t7,1'78 CELL 9A--,9 -- cfJda- EMAIL , ?o Q (4,,, CrQpzPrilucc(- (!JN-• ii/o/ _74/ 7 ' '' __ . If(vchi v.,s Cause &VcA)vtcc ( Nv F--•-€) �` ,Ni (Li) n g_ MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK trV' fl`/S-Od( it'_ _ 07Y I q to r^w hr..k." MA DATE y 1 PERMIT!! 57 JOBSITEADDRESS' 59 7 F(i S f' 24 IoWNER'SNAMEI 71Wd 0f Via retiCi t GOWNER ADDRESS I 02J-- .11 cl• ‘YrY ern.tI TEII IFAXI TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL© PRINT CLEARLY IEWD RENOVATIOM EI REPLACEMENT:a PLANS SUBMITTED YES❑ NOL APPLIANCES Z FLOORS-1 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 BOILER _ - _ BOOSTER' MN�;a CONVERSION MSanat.mat COOK STOVE DIRECT VENT HEATER 111111.111ass a semamil FIREDRYEPLACE OM OS R n 'WNM Saff. FRYOLAT a:• ��n� rStSerr fSf — FURNACE NMI SIN MN.—MI NMI a LS 111M Ma iKlam,NNW is, GENERATOR SIC . SSSS C—S— — GRILLE ll S - ,ter. INFRARED HEATER LABORATORY COCKS ---- --- Mr S MAKEUP AIR UNIT OVEN I POOL HEATER ROOM!SPACE HEATER ROOF TOP UNITr. TEST UNIT HEATER t NVENTED ROOM HEATER , , gals a INSURANCE COVERAGE ry1L/:rte., : , or Es substantial equivalent which meets the requiements of MGL Ch.142 YES SNO '•c , y5 „TETHETYPEOFCOVERAGEBY ECKINGT EAPPROPRIATEBOXBELOW LIABILITY INSURANCE POLICY LOTHER TYPE INDE/ANITY 0 BOND El 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 signore on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT C SIGNATURE OF OWNER OR AGENT I hereby certify anal tie of the details and Intern/atm l have submitted or entered regarding arb application are byreI�anda1 to the best of my Imowllu end srchu eamrWroPlumand Codeand hapter14 under the LaseuedtaraasapplkaaanwitbeIncal/�tproNsbnoface Massachusetts State Plumbing Code and Chepher 142 of the General t.awe. PWM8ER-GASFITTER NAME A/ 4,�c, n o I LICENSE# 90/r SIGNATURE MP[, GF D JP❑ JGF Q LPGI D CORPORATION[3i .3PARTNERSHIPDI—I LLC DA= COMPANY RAO Cm()e. (o44 1+1 utt..w u t. I ADDRESS ¢g Yr'llcja t Atte CITY I ,S .of n thannout'n. I STATE ma ZIP) O).CoC4 ITELI S - 3 gq -73"0/ FAX ICOA72C 1calI fit-tf?oa-lEMARI Cr'b 4_ /L`lo Codd /'LzrAanG 4 .• Co•fw 7s7A G 12/7L- S 3ir