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Home My WebLink AboutP-15-1763 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK er/ CITY W 1 �(�r{�'}(�U��1 I MA DATE PERMIT# /.�011-K-ery 11-6 3 JOBSITEADDRESS '3 1')(\otr) S \• 3S OWNER'S NAMEC(ft 'ljC , F(hp.r+ OWNER ADDRESS 2I7 41 TE ji1 uraFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIALItr PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Ij# PLANS SUBMITTED: YES❑ NO❑ FIXTURES 1 FLOOR-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 S i ., :i [a',,a a', BATHTUB �,��,I CROSS CONNECTION DEVICE MOM INIMIflaalallIMISallUallin DEDICATED SPECIAL WASTE SYSTEM .1111,011111 ,aa,a ii is iraa!a a DEDICATED GAS/OIUSAND SYSTEM I♦,Salarn.a,ia—ra S •S Ia,a= a DEDICATED GREASE SYSTEM MOM afaa,a a s,a a a a a MI MN l DEDICATED GRAY WATER SYSTEM �,��„�ars.�,�, m, mw �,ia DEDICATED WATER RECYCLE SYSTEM .1110.11111111111•11011M MIMI a a Ia a 0. ala DISHWASHER l,S5AIM 5111.SI aaOaPIM MIN PMa DRINKING FOUNTAIN a'a r afIMAMOlaaMal a FOOD DISPOSER Mira 111111ra,MIaaiSWIMS a,a,ara.MIT FLOOR/AREA DRAIN 1111111111111 ,a ala a M,M.a,pm i.a,a.a INTERCEPTOR INTERIOR a;;aafa ! ,wiaaalanta,aa.. KITCHEN SINK 5, MIN MIN a;aaaaMa`salMS MOM a LAVATORY a,a,MI a a a,.a,a iia a a sa,� ROOF DRAIN a,1a,aaaaa5.5a,aaa.M SHOWER STALL 11111111a fl 5_IIIMICNIE.�, is ra a,;a a a SERVICE!MOP SINK 5 a alai,a',M OIOja a1S 5 mu[a s TOILET INIIK OM aaaaaJOU MINI a URINAL MOM a alai'all.aalms naalaa WASHING MACHINE CONNECTION mf _5MINTIMINI Wan Sin Oita WAT• '44EATER ALL.TYPES •i ice a la a a a a a'la,a a a a 1,, . -aira a Mt if t;a a a;laON i IP - ' 1 ,015 .171:201.10[111111 JIM 0■1ta,a l a [01. I111la SI aaMSS i�■i'iaaaaa 1111111initlanBEASSI NMI la a MI aNMI:JIM aaa,oil l fa ,aala.nli 5 BUILDAL3 ort '- +,uvl INSURANCECOVERAGE: I hay• • 'a• • - .• .: •• icy 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 Ail LIABILITY INSURANCE POLICY 11Y 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 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and Information I have submitted or entered regarding this application a true and a urate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will 6;1,mpliance • all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBERS NAME Larnl'. Cnrvtrnl*-- ILICENSE# 0418 SIGNATURE MPO4 JP❑ CORPORATIONA]# 04(3 PARTNERSHIP❑# LLC❑#P COMPANY NAME Len , rw ,J1Ir ADDRESS ' CITY _ A I, a STATE MI ZIP rallaillielan. FAX 111111111111111111 CELL, i 1 EMAIL i I IsQ�A 71t •w ! •w • •! �I� 560434C /- 'N ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ 0 FEE: $ PERMIT it PLAN REVIEW NOTES • t _� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK s 1 I '�^ D' X411= CITY VV • \I(1{1�{��1 Y \ MA DATEV4 PERMIT# &QCT-/S /ha- JOBSITETE ADDRESS, (•?j to S4 . �r3IE OWNER'S NAME.I, !aril( P1 p t N rf GOWNER ADDRESS I JTE ' a 4' Axl I TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL .4 PRINT CLEARLY NEW.r-1 RENOVATION:❑ REPLACEMENT: II PLANS SUBMITTED: YES NO APPLIANCES 1 FLOORS-. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER a.5f5i i5.IM ,:PIM_ 55(5a�.a BOOSTER a a.sa -a;I sal �;I : CONVERSION BURNER a[M[ 1111aal=IIIM,ONSIna ajar e5 COOK STOVE a,,ai,n NM Linialliii,NSW.MM.a MR DIRECT VENT HEATER C55a aS 10 111011 SINE MIS an DRYER a...a. n a a Mg OW MISI5CIS I ,M,IM FURNACE .i! a®s:� NMRYOLAOR FIREPLACE MI�s.as,a,� AEOR � .II.a M[�at[�ia mile gma as aMIMIMaatC;aaa GRILLE IIIMItala la«al=a am sa wont INFRARED HEATER _aaaaa,a[asfs �'[u■oMal�I[ LABORATORY COCKS a.al a,llllll�a.5�;S P a a a la a MAKEUP AIR UNIT MI ONE Ulna a a a an Sna;[naft, OVEN artal111111,1.11_slla alma min MIMI POOL HEATER MI a fns;MN W,t';S...S5[Saim ROOM/SPACE HEATER55 rte; a aimilaa a,[-. ROOF TOP UNIT Ma's[I a a a 1ass a sa,a,i TEST =K.aaaMtaaalOE,aa,Eala UNIT HEATER 5555 ,5555 5 al 5 Eli► alit1aS SiU:S"ME 111.151111 moi P;[a_5, Imnglwra ffrnafills Mr_ 5SNa=_,S_S.a[■fir,: a aPRIXssns;sa.ss_anMSS f . . t1monoaiii'{Ioomilmtle iaapokl Danm[1141[ IIIIIMMErf//IAS INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES .NO El I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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 0 SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and Information I have submitted or entered regarding this application are t •0 and accurate the best of my knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be In co, •fiance with ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME IL.&rr19 .tg-Yht^n rx I LICENSE#Jaalli SIGNATURE MP 21 MGF❑ JP❑ JGGFF Q LPGI❑ CORPORATION F;tj# 33( L40 PARTNERSHIP❑# LLC❑# COMPANY NAME:(EH Ylt1'r1 iryJ;4nr fir- ADDRESS I '& IIfor 1 CITY Lin( STATE ti/-4 ZIPf(OS ITEL WI (A' I-4-?4I I FAX CELL-k11CA (44i41EMAIL4rnwham a.)JornplurntStr1Gj . CotYI I ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES T