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HomeMy WebLinkAboutBLDP-19-003225./",I'�-lGp. 0/1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK DWITY P TYPE OR PRINT CLEARLY MA DATE PERMITS JOBSITEADDRESS ��bny���i��ppp�IQ OWNER'SNAME OWNER ADDRESS .�.11'ylX.i TELJIA-31h� FAX OCCUPANCYTYPE COMMERCIAL [:1 EDUCATIONAL ❑ RESIDENTIAL+ NEW: ❑ RENOVATION: ❑ REPLACEMENT: ] PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES 7 FLOOR— BSM 1 2 3 4 5 6 7 6 9 10 '11 12 13 14 BATHTUB CROSS CONNECTION DEVICE' DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND 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 ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW - LIABIUTY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ 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 ❑ 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 cemplia ith all Perti rovisionf the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. eFz PLUMBER'S NAME Cur 1 S . f� i ecl e - I I LICENSES 2'4 yj !�' SIGNATURE MPM JP ❑ CORPORATION ❑ S PARTNERSHIP ❑ S LLC ❑ S COMPANY NAME (— c. r 1 F. R � ecl e l l r Son ADDRESS -7'?'R M t're e} CITY 05tecyi112 STATE MA ZIP r)D&55 TEL 50S--Hr�`S-Co3Co FAX CELL EMAIL 0/1 .' y -c �2 � � ��a�� Pcrce l MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CIN 1 N F=1 MA DATE PERMIT # JOBSITE ADDRESS OWNER'S NAME I W114 11111 G. OWNERADDRESS TE FAX® TYPE OR OCCUPANCY TYPE COMMERCIALQ EDUCATIONAL 0 RESIDENTIAL( PRINT CLEARLY NEW:❑ RENOVATION:n REPLACEMENT: PLANSSUBMITTED: YES❑ NO[] APPLIANCES 7 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 14 BOILER BOOSTERCONVERSION d12213 BURNER ItCOOK STOVEDIRECT VENT HEATER LIL DRYER FIREPLACE FRYOLATOR FURNACE 77711 GENERATOR GRILLE __ ..:.! INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN � _. �I— POOL HEATER ROOM /SPACE HEATER L,-.. I I_.. . .. _ ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER Al WATER HEATER _ OTHER) f 1— INSURANCE COVERAGE I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES QNO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY � OTHER TYPE INDEMNITY © BOND F1 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 [j AGENT Q 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 complia ith all Pe iaerf provi he Massachusetts Stale Plumbing Code and Chapter 142 of the General Laws. _ PLUMBER-GASFITTER NAME I C a r I S. R i e ci e 11 LICENSE #&�'Z 6 S ATURE MP ;4 MGF © JP Q JGF Q LPGI Q CORPORATION ®# PARTNERSHIP®#0 LLC Q#F COMPANY NAME1 C cart F. r Son ADDRESS 1 -778 Mc. in Streek- CITY OStervllle STATE�21P TEL 1 15 0S- ydFs _3 FAX CELLrEMAIL r��