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Home My WebLink AboutBLDP-19-002722 rAC ✓ ~„ MASSACHUSETTS UNIFORM APPLICAT1ONN OUR A PERMIT TO PERFORM PLUMBING WORK ,� CITY Y 1° CW'7 I Y01 MA DATE 11 5/I f ERMR#%l`�/P�\/ � JOBSITE ADDRESS - . P CC , .r,Je I OWNER'S NAMEt911'& \ ,/— POWNER ADDRESS C,loirk, vt.rwuntii4,. TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL[r PRINT / CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:2PLANS SUBMITTED: YES❑, NO❑ FIXTURES 1 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 GAS/OIL/SAND SYSTEM _ DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER • DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) ECF , V ^ U _ KITCHEN SINK LAVATORY ROOF DRAIN NOV v Zi SHOWER STALL • SERVICE I MOP SINK BUILDING DE••ARTN ENT i i TOILET eY URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES sC _ 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 lie/NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY p" OTHERTYPEOF 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 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 an plumbing work and installations performed under the permit issued for this application will be In mpliance w -t all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. • PLUMBER'S NAME , LICENSE#00€383 SIGNATURE MP 0 • JP IE t� CORPORATION 0# PARTNERSHIP❑# LLC 0# COMPANY NAMESulear„?yc \L)k4&rnet ft11Ce( ADDRESS re)S. s40 siN P CITY r-- sVEws\-e r J STATE IAA ZIP Oa 3 1 TE07+-S7g-5.9 AA FAX CELL EMAI . . • C .. . ,.. • i' • G 1 r`� h lk cic-t-if 4 O ROUGH PLUMBING INSPECTION NOTES fELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 0 FEE: $ PERMIT PLAN REVIEW NOTES Aptetrar Mil ' 4,1 _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK er- e CITY vprvv‘a%Jk- .., MA DATE /At 13 PERMIT SM4P-Mi d/xg JOBSITE)ADDRESS 7 - I�GP notn br11/P _ OWNER'S NAME TO INN 14e.i e r GOWNER ADDRESS E J1u. uacm00a 1,. TEL NIX- PRINT TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL LtdAX PRINT / CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:[t PLANS SUBMITTED: YES 0 NO 0 APPLIANCES 1 FLOORS-4 BSM 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 fiat-7W! MAKEUP AIR UNIT OVEN POOL HEATER f jUY2fi}(i ROOM I SPACE HEATER ROOF TOP UNIT TEST DING OEPA 4TMl=NOYI UNIT HEATER UNVENTED ROOM HEATER WATER HEATER >C OTHER INSURANCE COVERAGE �� I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES L1 NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND 0 • OWNER'S INSURAIVCE 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 YIN 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 complla ce with II Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTERNAMEE LICENSE It.a0993SIGNATURE MP❑ MGF 0 c JP[� IGF❑ LPG' 0 (CORPORATION❑# PARTNERSHIP 0# LLC❑# COMPANY NAME 7..1p Any ILMAI` St CNJ10ES ADDRESS I (1S— F YU (o+vN CRY r WST'P r STATE Ma ZIP Q,2(o4 I TEL 774-rig tr?L-P FAX CELL EMAILS4H.vre/ vnn}31nvcerUICPC@C_rhAf (� Lhl c IwU :190' ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 0 • • FEE: $ PERMIT I! P-4:11/44-1/ 645 PLAN REVIEW NOTES Mir • Mme:% • a