HomeMy WebLinkAboutBLDP-15-000616 •
tZ., MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
`:S—E 'e b CITY Y0.c?rt�v, Poct — MA DATE~$ Og 1 ( PERMIT# P'/S—C�G�C7/(t
JOBSITE ADDRESS S'a 13o rt \e OWNER'S NAME k • \1 4--.n a 2 rt n.e.:
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OWNER ADDRESS 49 �A.� h St�ctt Wcy..no �1ly TEL 339 .._ _ _ _a 'FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL h RESIDENTIAL{
PRINT
CLEARLY NEW:0 RENOVATION:f�.. REPLACEMENT` PLANS SUBMITTED: YES[„' NO _.
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
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK
TOILET
-
URINAL
W -
W' FAHEATER Aft y YFI U Z
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AJC, 18 2014
bUILLTh I �/J ,/�
v/�/��] INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES{-17 NO ,„-
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY; I OTHER TYPE OF INDEMNITY j . ,i BOND I r_
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 1-
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 end installations performed under the permit issued for this application wiU be i pliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ____ n ,/_ a/B aG^—
PLUMBER'S NAME Peter Wallmann LICENSE# 11447 SIGNATURE
•
MPI' JP't CORPORATION. '3# 33470, PARTNERSHIP ,#;._ LLC #j,.
COMPANY NAME. Peters Plumbing&Heating,INC ADDRESS,P.O.Box 485
CITY I Lunenburg STATE i MA ZIP i 01462 TEL I 978-582-7207 4
FAX 978-58217207 CELL i 508-331-3180 - EMAIL 'petesplumbinc@aol.com
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
YR_ ,—
• .12-2111k71 CITY Y0.1 t-ov _ dost...: • MA DATE 9-01 1 . PERMIT# S >'iY1JJlt/6
JOBSITE ADDRESS 5 a ear no c\-e v a ,OWNER'S NAME LAJ Be noel
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OWNER ADDRESS G5_,. Std.,a'1s1'I. .. Stt co-1 TEL 33 9 ;� 3� 419aFAX +
TYPE OR OCCUPANCY TYPE COMMERCIAL ,. EDUCATIONAL RESIDENTIAL')C
PRINT
CLEARLY NEW: .„' RENOVATION: REPLACEMENT:'( PLANS SUBMITTED: YES NO.
APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST
UNI-kIEAT€R
UNb EIytED ROOM.NEA�tE�RTI=
WA-ERT 7 #r7orl 1
I
orE ER AU 18 2014 . �b
BUILDING U��y"�y TM:NT-
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES t! NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCEPOLICX_ OTHER TYPE INDEMNITY BOND .,
OWNER'S INSURANCE WAVER: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 compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME Peter Wallmann ' UCENSE# 11447 SIGNATURE
MP + MGF JP + JGF ' LPG! CORPORATION !# 33470 PARTNERSHIP # LLC ,#
COMPANY NAME: PetesPlumbing&Heating,INC -- . , ADDRESS P.0 Box 485
CITY Lunenburg ..,__ STATE MA i ZIP 01462 _.,!TEL 978-582-7207
FAX 978-582-7207 ; CELL 508-331-3180 .'EMAIL petesplumbinc@aoLcom