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HomeMy WebLinkAboutBLDP-15-000382 c A8 LPO MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY.SAlax NAM 1I I MA DATE w man PERMIT# �J, JOBSITE ADDRESS � [)Ur\� �� , OWNER'S NAME r ,a/ -ft n a} P OWNER ADDRESS 7- TEL C1I R ?(f{ cAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL PRINT �( CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT: fl. r PLANS SUBMITTED: YES❑ NOD FIXTURES 1 FLOOR-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB � i, 1 t r --- .I CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM I _ I li_ _ .I DEDICATED GREASE SYSTEM j i r � DEDICATED GRAY WATER SYSTEM , I ,m DEDICATED WATER RECYCLE SYSTEM 1 1 —I Br ,l ' , SI i - II! a; 41 DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER ,I i FLOOR IAREA DRAIN ' _--- � ' r, 1 i OR) 101:11. a ii � _i ROOFDRAIN sL SHOWER STALL , SERVICE/MOP SINK 1I- r r TOILET URINAL _tta WASHING MACHINE CONNECTION I!IIIIiiR5IiII WATERHEATE• A_ • 0 I •- ,I■I■A11.„ ■f l®11, - ,N, mt, , ) t tease BUILDIN A As INSURANCE COVERAGE: a I h.yogi'turret faCisiliTEMolicy or its substantial equivalent which meets the requirements of MGL Ch.142. YES(i NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ek 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 E 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 ar true and accurate best of my knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be In Miles with a err ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. f.. PLUMBER'S NAME �,A e[/ I{1 arm l ye LICENSE# /291-01 / SIGNATURE (>1111\ JP CORPORATION # 3/0L10 PARTNERSHIP ' # LLC E1# COMPANY NAME 1/4 STATE P1 vitil b) nal ADDRESS / �,(f p I In Gr - on--i ' K as r CITY L/400 1/4 STATE I _ ZIP O - c Z TEL 40 1 (039- L/84/ FAX CELL EMAIL hn'{',b)0114hi 1 C7rrm PUrrtbiViolr On hi ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT Ik PLAN REVIEW NOTES { gb-02 aco1 a- Pa _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �pW,_e', - `:'-F:L--!C CITY ,\ 0 min( ).F ! MA DATE ,Ai7L'9 PERMIT# I ii•- - V JOBSITEADDRESS, . trbnlJr.4 S# • OWNER'S NAME " , n • GOWNER ADDRESS I TELR7R 1NX SLI ?,(FM TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL/0 PRINT �,�� CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 7 6 I 9 # 10 11 12 ' 13 ) 14 BOILERI j BOOSTElEE:: Rfir-f � f r -MN MIS. illial lila DRYERr—_ SWIM M' —. �r FIREPLACE SIR FRYOLATOR Ian sworn.iim; __ s FURNACE GENERATOR 11111111111 ar GRILLE 1 INFRARED HEATER iiiallialilil ilillitiligaNIII aill Olgralliti LABORATORY COCKS01.110111111a,. " MAKEUP AIR UNIT ONUS Ininaitil.failieniall. OVEN POOL HEATER t Ma ill NM SWIM - .r ROOM/SPACE HEATER ..-' - S f, ROOF TOP UNIT ; ',( ' TEST SON.a.— UNIT HEATER _ .,SS •- TTS .farr4 . ea�tIEA.E.FD -- I -Sr naHE3I�'',�ginillire fn� n , Mita ,a1,1 . . : . S _ -.._..:.-- 2TMENT 1.� l�r_��S u Il . 1 , .-..... BY:_-- INSURANCE COVERAGE ave a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 8-NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY IZI OTHER TYPE 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 El 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 - d 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. - ce with all Pe ent • - ision of the Massachusetts State Plumbing Code e-anndChapter142 of the General Laws. _. Ad PLUMBER-GASFITTER NAME 4v1 i p� I 0-.F 41A LICENSE#9q?• _ ' or SIGNATURE MP ElMGF ID JP ElJGF❑lLPGI❑-'" CORPORATION 2 f d 4O]PARTNE•.. P❑# LLC❑# COMPANY NAME: dem—Plvrn(3r(\ `, ADDRESS 11.4).cII/net -p✓t 1sn.A. CITY LLAW LaI/-, Q STATE 2T ZIP /�Ol%4,S TEL gal- 6,3ct- 21,9I-8FAX CELL EMAIL-Hr./4thm( l..,flern L QnV\oiv ' CO len, 5g g6340 as — am ROUGH CAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 0 0 FEE: $ PERMIT It PLAN REVIEW NOTES