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Home My WebLink AboutBLDP-19-003062 I/P cfl Llp /COCK - . . • $) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ::-‘37#—:: CITY/TOWN J Ott' y9,ferrn✓7 X MA DATE i I /I`III f •PERMIT#49—/9-09 301'11, JOBSITE ADDRESS 9 q tel evOWNER'S NAME ?'�3l/) /by/7k Z r k P OWNER ADDRESS TEL FAX r TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL PRINT _, / CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:U2 PLANS SUBMITTED: YES 0 NO FIXTURES 7 FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 1 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) • KITCHEN SINK _ _ LAVATORY ; V ROOF DRAIN I • SHOWER STALL SERVICE I MOP SINK • I NnV 1 64,018 TOILET URINAL f i, niH :rvr Al TrZ_N7 WASHING MACHINE CONNECTION WATER HEATER ALL TYPES - l 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 E1' NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW HE LIABILITY INSURANCE POLICY Q 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 0 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 corn ran with all Pertinent vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. fY/% PLUMBER'S NAME -Br f ll-Al h,i14 t ed LICENSE# /I N 17 SIGNATURE MP Er L�/JP 0 CORPORATION s PARTNERSHIP 0# LLC 0# COMPANY NAME CSE cod PIUn,brof ADDRESS Pi, A'nX q Z 9 • CITY 5; DC 461//l STATE A79- ZIP jj 2 66 0 TEL FAX CELL EMAIL CI643 cA Ldr`FD • I C ,fie 2 r Z ae6 fiA 007 •r•• MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK • • et CID( Si,u71 y,,,,r-m on/ MA DATE /1/Yv/1P PERMIT* b-d1950 4 JOBSITEADDRESS• '111 Lei'ids 3 I�/lil OWNER'S NAME / AA,/7lr/7;if G OWNER ADDRESS TEL FAX ," TYPE OR OCCUPANCY TYPE COMMERCIAL CI • EDUCATIONAL ❑ RESIDENTIAL I/1"- itac o'oU PRINT —/ CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:2" PLANS SUBMITTED: YES 0 NOI' APPLIANCES 7 FLOORS-' BSM 1 2 3 4 5 6 7 8 0 10 11 12 • • 13 BOILER BOOSTER • CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR • FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT • OVEN . ! R _ G ` : 0 POOL HEATER ROOM I SPACE HEATER ' • ROOF TOP UNIT IVUV 16 TEST • UIT HEATER i 8U LDWF 4rof RTAAL IT UNNVENTED ROOM HEATER L2.32 _ — WATER HEATER I OTHER INSURANCE COVERAGE I have a current)lability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES I1410 ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIIJ1Y INSURANCE POLICY 0 OTHER TYPE INDEMNITY 0 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 0 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 known and that ell Massachusetts State work and Installations Plumbing Ater 142 under thepenal Laws.t issued for �application will be In. with all_ Pertinent rovision of the PLUMBERGASFITTER NAME . UCENSE#11477 i-efJ/C•/�SIIG-NATURE MP I/ MGF❑ is❑ JGF❑ LPGI❑ CORPORATION Le# PARTNERSHIP❑# LLC❑# COMPANY NAME C.idiot a." ?iumitIn5 4'Rif •T✓t. ADDRESS `t'.0. /Sox 42-1 CITY S be-ay ii STATE 4a..._ ZIP 02(( 6 TEL Sol- 311) - zz2: FAX CELL EMAILt _ ,,Ca3L o� 6,d5 07( /2406y-