HomeMy WebLinkAboutBLDP-15-000493 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
1-5:17__ ;- CITY Y\. ' n
4GLYYY�,Ul11r 1
MADATEDATE 1 Lot I`i' PERMIT# D�1GAO pp
JOBSITE ADDRESS 15 1-I�b✓bar- Rol OWNER'SNAMETIIQUr'an Ia.t
•
OWNER ADDRESS TELa1 ' 3(1 0241 I
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALA
PRINT
CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES 0 NO 0
FIXTURES 1 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/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
W:T[R TLER`it IY'PES_ D I
0-HER Io'l 97-
ALG 1 1 2014
Pull t; NG RTMENT
INSURANCE COVERAGE:
I have a current liability insurance 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
LIABIUTYINSURANCEPOUCY OTHER TYPE OF INDEMNITY 0 BOND 0
OWNER'S INSURANCE WAIVER:l 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 arI rue and accurate to e best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in fiT pliance with - '- • ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME L' rr5 T G tmrn 0. LICENSE#\ b)el SIGNATURE
MP® JP 0 CORPORATION®# 3ci(c PARTNERSHIP Pd LLC❑#
COMPANY NAME%Et`I C.1)( Q.• Iht. ADDRESS \ \JO%, VIItskoh �CL
CITY \--i`t� e o� c� STATE tt ZIP a 2°s 6 5' TELLk 6 le\ 4`c'i 1
FAX CELLL{Co1GV\ L\ 41 EMAIL kkenek\ .t:.cn@CiMeAtAtrt\mriJ. C,eM
°La 30
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
1^w
VT. .4 CITY V�1 W . \as noUl r ` MA DATE (pi �-�' PERMIT#j3.40 . 9/1_9..4
JOBSITE ADDRESS \5 \ado r t `d OWNER'S NAMESI�UrLtr \<ci&��S
GOWNER ADDRESS TEL a72 ?ttl d.4.1 I
TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIALLA
PRINT
CLEARLY NEW:0 RENOVATION: 0 REPLACEMENT:[ PLANS SUBMITTED: YES 0 NO 0
APPLIANCES 7 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
UNIT HEATER
'lT E1F�i ADS/N&AER9
OT Et( ?ad./ 7U / I
19112Qi . .
.. l, c, f4 _.arzTMENT INSURANCE COVERAGE
rhave a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ® NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Ri 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 ❑ 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 ,s d accurate to the best of my knovAedge
and that all plumbing work and installations performed under the permit issued for this application will be in comp a.ce with all P • ovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Id Ae
PLUMBER-GASFITTER NAME \--We' 't G-e vlC1 LICENSE#r'el79% SIG'ATURE
MP ix MGF 0 JP 0 JGF 0 LPGI❑11`` 11CORPORATION®#3C 9 0 PARTN • '(1_�❑# O 1 LLC❑#
COMPANY NAMEV .t'�I c)\tAMbt nts#Ake�\1n to tint ADDRESS W t\11n5*e h VAC
CITY \m C cN v, STATE $t ZIP case c, TELI.A N c a\ Liss LA i
FAX CELLLIOt ca MCstit EMAILa co a x- b,vinq of v,n SZ _VNrnbw . Ctan
5 isga30 80