HomeMy WebLinkAboutBLDP-19-003129 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
='a_ CITY__R.MAu MA DATE /D(1 t(I PERMIT#*dP -604.5/A/
JOBSITE ADDRESS /D CL'e04v/ CANS OWNER'S NAME
POWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL''
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT`.'# PLANS SUBMITTED: YES❑ NO[ir
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/OIL/SAND SYSTEM _
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM _ ACT 11 11.118
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER DINo-DEPARTM NT
DRINKING FOUNTAIN _____,—
FOOD
-,—FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
j LAVATORY
ROOF DRAIN
SHOWER STALL
•
SERVICE I MOP SINK
TOILET
URINAL-
. WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
t I -
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESIe NO 0
IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABIUTY INSURANCE POLICY 0 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
L 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 all plumbing work and Installations performed under the permit issued for this application will be In compliance with all Perlipent provisi
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE#)48C?9 SIGNA1U E
MP W JP //,,//,, __ vCORPORATIONNS zip 7CPARTNERSHIP 0.# LLC❑#
COMPANY NAME 41.1 /Y ( �evU ADDRESS ae Me-2—/Sr4'
CITY 7/41 / 1 /y /'7 /Pool
FAX ✓ CELL 4... -047_D4... -047_ j7//
/4 3 EMAIL 4 jMt/C ll/SSCiO Yt f e,iti
•
c •
Yrnic
� SfOM MaIA1I
/) id s�� #IIwa3d
:33d
0 0 11WU3d 3H1 SV 93A213S NOIlVOIIddV SIHl
oN CaA
Sf.LOM NOT.LOL ISNI 1VNIg A'INO 2190 210T2I301IO.T M01fl$ S2.IA1.1 NOIJ32HSNi`JNIflIWiflld HJ001
•
•—A`` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
c oin CITY 4 r14 -/Y10K L MA DATE IU///i8 00..3/A9
/ PERI�AIT�
JOBSITE ADDRESS IQ (_'I,fizeelL A.tIr- OWNERS NAME
OWNER ADDRESS TEL _ -. FAX
•
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL
PRINT
CLEARLY NEW❑ RENOVATION:0 REPLACEMENT:: PLANS SUBMITTED: YES 0 Nl
APPLIANCES 7 FLOORS- OEM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
•
BOOSTER
CONVERSION BURNER 1�
COOK
DIRECT VENT HEATER k I )
DRYER p�
FIREPLACE ULT 11 Zing
FRYDLATOR
FURNACE e PA
—�
GENERATOR
. iv
GENERATOR
GRILLE
INFRARED HEATER
LABQPATORY COCKS .
MAKEUP AIR UNIT
OVEN
POOL HEATER •
ROOM(SPACE HEATER
ROOF TOP UNIT
TEST . ....... -- - --
UNIT HEATER
INVENTED ROOM HEATER _
WATER HEATER i
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [+ NO ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 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
and that all plumbing work and Installations performed under the permit Issued for this application will be in corn Hance with a Pe ' ent pawls' n of the
,yt Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITfERNAAM/E LICENSE#ive99 SIGNAKIRE
MPS' MGF 0 JP�q JGF❑ LPGI� 0 CORPORATION�4I 1/057 Ci PARTNERSHIP 0 it �1 LLC❑#
COMPANY NAME /�►-*L_ dd , 1INtr' QFCCUL7/f/ ADDRESS /IrLi fA- 46h/Pe-
CITY yN'1M0+4 9-1„-- p �STTATE MA a ZIP 0 23-� TEL COQ 7-0100/
FAX CELL GOO /o'o n/3 EMAIL , dm. -_
ROUGH GAS INSPECTION NOTES
THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT 0 0
FEE: $ PER1R ftrI////tI sa S
PLAN REVIEW NOTES