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Home My WebLink AboutBLDP-19-00451 • MASSACHUSETTS UNIFORM APPLJCATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY T rnLr LA. S�MA]] DATE 16 -02 S.- (1 PERMIT# 641)P-ft-tooo�}� JOBSITE ADDRESS 1j6 1, 1an '1ZU2 OWNER'S NAME 1-tic, (In OWNER ADDRESS 5 GM'a— TEL FAX TYPETYPE OR OCCUPANCY TYPE COMMERCIAL 0 , EDUCATIONAL 0 RESIDENTIAL L� PRINT CLEARLY NEW:IDRENOVATION:❑ REPLACEMENT:[W • PLANS SUBMITTED: YES❑ NO❑ FIXTURES 1. FLOOR–. BSM 1 2 3 4 5 6 7 B 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 FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES f WATER PIPING OTHER INSURANCE COVERAGE: a( I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Q NO 0 IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POUCY are OTHER TYPE OF INDEMNITY ❑ BOND 9 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the �t 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 LI 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 compile with all Pertinent provision of the Massachusetts State Plumbing CodeandChapter 142 of the General Laws. PLUMBER'S NAME Jtcve11be‘g- /LICENSE# IJro1!9. [/SI TURE MP L2 JP 0 CORPORATION i# PARTNERSHIP❑ LLC❑# COMPANY NAME Tro,4 J R Vumir,ilicr ADDRESS 'Ili �7,1 L() ;Oslo- CrY'un I /• CITY 5 V4v VH n {-i STATETVG ZIP 0.2 to if TEL 735ry FAX CELL 9ci 42- EMAIL 3 Kr,rlaor nie-i23 prlait i .6oLt•J ROUGH PLUMBING INSPECTION NOTES f FLOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT R PLAN REVIEW NOTES w • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK "p G i� CITY YcwYtLo(, MA DATE 16 -2 (-1S- PERMIT# ,e(-40-- -€V.21/,tf JOBSITE ADDRESS ) yG 1Dyevl a. (17.e_- OWNERS NAME j. ea,La OVJIJERADDRESS 43Aw1e_ TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL lg PRINT CLEARLY NEW:❑ RENOVATION: 0 REPLACEMENT:L PLANS SUBMITTED: YES 0 NO 0 APPLIANCES 1 FLOORS-. 651M 1 2 3 4 5 6 7 3 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE 1 INFRARED HEATER LABORATORY COCKS . MAKEUP AIR UNIT OVEN POOL HEATER • ROOM I SPACE HEATER ROOF TOP UNIT TEST _. .... . . . . . . .. ...._ ...... .. . -• -- UNIT HEATER LINVENTED ROOM HEATER WATER HEATER 6 OTHER INSURANCE COVERAGE � I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ll-1' NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE E BY CHECKING THE APPROPRIATE BOX BELOW • LIABILITY INSURANCE POLICY OTHER TYPE 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 a.`h+ 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 complia -a 'th a P inept provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / i A r- . i.e PLUMBS -GASFITTER NAME LICENSE# f 621 i SIGNA RE MP II MGF ElJP❑ JGF EI LPG!❑ CORPORATIONi ❑ PARTNERS IP❑# LLC❑# COMPANY(NAME �uV'eLI r QIf�1�b 10 c� _ ADDRESS y/ `7 7 t/t W 114 i0 /./J �rtr/.-y. a CITY 3/ NwGV 0 u t V\ STATE NIA ZIP 63 6 6 TEL FAX CELL 5 CQIM P EMAIL , t' ' /J III , 1 C 14 , f/2 %/ / 7 , 270 --ii 0 i--kfrii*J . ' ,