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HomeMy WebLinkAboutBLDP-19-003142 ' a MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK � CITY ae4iOdtl MA DATE if as//40 PERMR# ant/C-69gia JOBSITE ADDRESS r X &ca /La OWNER'S NAME Ok 5 /94.24. a/ POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL[r PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:[f PLANS SUBMITTED: YES 0 NO 3/ FIXTURES 7 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 I VT. �, FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK j NOV 2-0 Z�1� LAVATORY i ROOF DRAIN HUG UYAN ILIHNCI I4I[ I SHOWER STALL Ii '21--= — — SERVICE I MOP SINK I TOILET URINAL • • 1 WASHING MACHINE CONNECTION WATER HEATER ALL TYPES / WATER PIPING I OTHER 1 f ' INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Cit 142 YES NO ❑ , • IF YOU CHECKED YES, PLEASE INDICATE THE TYPE DF COVERAGE BY CHECKING THE APPROPRIATE BOX BLOW LIABILITY INSURANCE POLICY.6 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 1 Massachusetts General Laws,and that my signature on this permit application waives this requirement I CHECK ONE ONLY: OWNER 0 AGENT ❑ SIGNATURE OF OWNER OR AGENT I l 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 a8 plumbing work and Installations performed under the permit Issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Ci;pter 142 of the General Laws. PLUMBER'S 6(Aer ya4e-d LICENSE# gg,0 � • SIGNATURE MP aJ ' JP❑ CORPORATION�p0 it PARTNERSHIPLIP❑# �LLCC E## ;$1‘ COMPANN��Y''NAME6 -% t3 /led ADDRESS l/� fd�</� cif u' /Ur q CITY Ga Z eic STATE d ZIP e', 61,3 j7 TEL`7C - 747Pc • FAX CELL EMAIL ' Ott 112# Z_____.a/) ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 0 , FEE: $ PERMIT# ►i PLAN REVIEW NOTES k 4 4 ©/ - 17. ► ferMASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK JCITY Y!!?'h Dd lMA DATE /090a PERMIT k nC7C JOBSITE ADDRESS 3Y We-47,41g/ / OWNER'S NAME e/47t2 OWNER ADDRESS • TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL El PRINT 1 CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:EJ PLANS SUBMITTED: YES 0 NO cfr APPLIANCES 7 FLOORS-' BSM 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 .—L F I V F_ GRILLE —I INFRARED HEATER - LABORATORY COCKS _ (WV 2u Alb ! MAKEUP AIR UNIT OVEN RLiILJING f)EPAFTMET POOL HEATER • II to, ROOM I SPACE HEATER ROOF TOP UNIT _ TEST ... -- UNIT HEATER _ INVENTED ROOM HEATER _ WATER HEATER / OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142 YES ZNO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW LIABIUTY 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 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 3- and that all plumbing work and Installations performed under the permit Issued for this application will be in compliance with a -ertinent provision of the W Massachusetts State Plumbing Code and Chapter 142 f the General Laws. PLUMBER-GASFITTERNAME a" ' exiwGs LICENSEI Beg, /�SIIGNATZA UR (O �/ 2 / MP d MGF 0 JP❑ JGF 0 LPG' ❑ CORPORATION❑# PARTNERSHIP 0 it LLC 2 t COMPANY NAME 64*722ou4.i 01166 ADDRESS4VA-24'&47 . CITY�C/i �� / STATF ZIP 6,642.#' TE / �,� I'/ FAX CELL EMAIL I &4D c#d • • • • • • � 7� // S'�ZON au him( N/I t L #1f69!!3d $ :33d • ) t !�-/ j ;6 ❑ 0 1169?13d 3M1 Stl Saims N011v011ddtl SIR!""IIJJ .� aN saA SALON NOI,L7adSMI'IYKU KING aSI1II01.3ad3NI Hal aDva SIHZ S .LOM 14OI1DadSNI SVD HO(IOl1