The URL can be used to link to this page

Home My WebLink AboutP-19-3401 • ✓ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY a a MA DATE PERMIT# gA0A 199X1%/ JOBSITE ADDRESSci) `Q I I`Y14 l rt-1 • OWNERS NAME1��)_1pptj j4er I .Si�t1 OWNER ADDRESS TEL lb-S PAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL Yr PRINT CLEARLY NEW 0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0 FIXTURES 7 FLOOR-' BSIA 1 2 3 4 5 6 7 6 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) J KITCHEN SINK LAVATORY f<TE Ci E rV 0 ROOF DRAIN SERVICE STALL 111201: �. SERVICE 11dOP SINK TOILET URINAL r kit.) ry'n j i-i wi WASHING MACHINE CONNECTION WATER HEATER ALL TYPES I — 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 0 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY ❑ OTHER TYPEOF INDEMNITY ❑ 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 IAI 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 N compUance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# (Ct(air I SIGNATURE MP ❑ JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME� �"11 l t _ eP(UYvlhl 0L9 ADDRESS02-(.014") , ( 2 C PrtVC CITY eis ' y`'' f► O '\ STATE ZIP VLl01 J TEL -77q-`610-1 (2-2- 4. • FAX CELL EMAIL 14:4af•! f • So 5hrt3Q,r . Wtce-;°telipni( Levy' ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 ❑ /�� Jn 7� / ?_ FEE: $ PERMIT if I 011t /% PLAN REVIEW NOTES 77f V ..""-eN, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Vi' CITY W-e Si' '(aVwt ` MA DATE PERMIT# *-4)79-a)5967 JOBSITE ADDRESS et' 4-e-atn lea ' OWNER'S NAME g1 U 4-4encknon GOWNER ADDRESS le TEL (aa-8tto `tlFAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL($( PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT:❑ PLANS SUBMITTED: YES 0 NO 0 APPLIANCES 1 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 J 11 12 13 14 BOILER _ BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE _ GENERATOR GRILLE - INFRARED HEATER i LABORATORY COCKS • MAKEUP AIR UNIT E EV OVEN POOL HEATER • �� j %t ROOM 1 SPACE HEATER 2R Pfl11I i ROOF TOP UNIT • TEST -- __ _.-1 ... . ... . ...._ _._. . r3L14�td.�t=Llan rn• UNIT HEATER BY. __ UNVENTED 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 12410 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY I39- 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 compliance with ell Pertinent provision of the W Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ^ 1/4---C----i•-•.— I PLUMBER-GASFITTERNAME UCENSE# Meg1 SIGNATURE INP 0 MGF 0 JP I .JGF 0 LPG 0 CORPORATION❑# prO2' PARTNERSHIP12)1/4511C-- � 0# LLC 0# COMPANY NAME MS-�jl/i 4 c_ p1 u tib t�`Fj ADDRESS �7c{ I,w K- a-r1V 1/Z17-- FAX CITY W€c tiAt e O STATE (Vt�`& ZIP 0 (913 TELiy34a1(.c �j��re 6/7JZ FAX CELL EMAIL 5+16 Cr-.MGM �':� avt all Eo ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 0 k %% �j�" a�/ FEE: $ PERMIT# OfC- '�2 PLAN REVIEW NOTES / /�/ /g