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HomeMy WebLinkAboutBldp-20-000010 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK t?" -CITY YA 12m o u� - MA DATE PERMIT#fiAip `aO0 0[OO JOBSITE ADDRESS -3 I ®mot,Hers c,..4 l\ I OWNER'S NAME 4 PJc,mi)ipy 1 POWNER ADDRESS TES , 3 . -Ae7IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL© EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW:© RENOVATION:ID REPLACEMENT: PLANS SUBMITTED: YES® NO❑ 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/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN "i FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR INTERIOR ic MIR-- ! R"' 1 SERVICE/MOP SINK 111111111M11 11411. TOILET URINAL M-------IN IF 11111T NT FISTITIIII Old WASHING MACHINE CONNECTION 11PVIIIIIIIIIIIII 1111,11111111 SW 11111111111111111 IIIIIi,Mir Ali ill y ilow OTHERiii, ...I. WATR HEATER ALL"fYPES RR ow—.MtIMWATER PIPING WiiRRRERR Itilil#1=12111R simulim - - 'NW Willilrarn INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 12/NO Ei IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY d 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 1 hereby certify that all of the details and iufwmation 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 co Wince with all m • ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME j'.0.+r .ill G$f+c4 e I LICENSE# 1 ‘-O ((SIGNATURE MP[' JP® CORPORATION Nj#,:7%X C, 1PARTNERSHJ IP®# - _ _ .. LLC®# _ I COMPANY NAME ,,,I, -��}Jn.•,_ --._�ADDRESS 1I (iaih '' (7Gci --_ - l J CITY .W W. `%ern 0v4A ISTATE mil ZIP 02.67 3 I TEL (5 OE)-7-71- 4554 _ FAX bof-7'1 u- -il CELLLS01)3(A•37 EMAIL M, s4 • \ N ,A" v— _ MASSACHUSE i IS UNIFORM APPUCATION FOR A PERMIT TO PERFORM GAS FCTTINN WORK —; c; - - _, - iR00 '= ` CITY 1Town of "/,d p(ljo u-n4 - MA DATE, 4. n ,' j[ PERMTT#/ PA_'a"/b G - JOBSI TE ADDRESS I - - - ,` _!OWNER'S a-4 Pl ri rn p f' • OWNERADDRESS ? 50k 3b0_-Ltgq'7SFAX i TYPE bR / PRINT OCCUPANCY TYPE COMIEERCIALU EDUCATIONAL 0 RESIDENTIAL CLEARLY NEW:LI RENOVATION:: REPLACEMENT: PLANS SUBMIT Stu: YES 0 NO0 APPUANCES 1 FLOORS-4 BSM 11 2 3 4 5 6 7 : 8 I 9 j 10 I 11 12 13 14 BOILER - BOOSTER -- - — - Ali ili=alt - . co liar- COOK CONVERSION BURNER ;� STOVE _ ,- 111$ DIRECT-VENT HEATER DRYER FIREPLACE - FURNACE • GENERATORI BBB GRILLE IIIflhIIU1UIiI I FRAREO HEATER __=NUM 111111E.11ii NW I•!lamMS LABORATORY COCKS IMM IrtilailtWalli '4- . :+ ' MAKEUP AIR UNIT NW ME 111111 W>�:4i+. ' iK j L Jj OVEN- Nor ME NM 11111111E ►i15 1.14.1 i I1147 I4 ALL;U.ILI. 4.111111 POOL HEATER • 1>l1 l A-4_Uliiil_.Q.hit i __W 3_ ROOM/SPACE HEATER • in- ROOFTOP UNIT - n• u,;,. TEST UNIT HEATER UNVE NED ROOM HEATER -WATER -(EATER---- - - OTH:; = _ _ . - - i . _ _Ne... ..0' - _ -— 1 -e — INSURANCE COVERAGE I have a current eint liability insurance poly or its substantial equivalent which meets the requirements of MGL Ch.142 YES 1NO 0 I IF YOU CIS YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E OTHER TYPE INDEMNITY 0 BOND E 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 0 AGENT SIGNATURE OF OWNER OR AGENT - I hereby cerndy that all tithe details and Irdennabon I have submitsd or entered regarding this applca6on are hue and accurate to , -best rimy Imovdedge and that all plumbing work and insialialions performed urderthe perk issued fortis application mil be in compliance I P. Ravi:clan of the A State Plumbing Code and 142 tithe General Laws. it.A;// - - PLUMBER-GASFI ITER NAME I key;n cs f:aP . I LICENSE#1 16901 - -- - SIGNATURE AV 1.2f MGF D JP® JGF C] LPG!D CORPORATION Eat)a F b8 G 1 PARTNERSHIP I11•" 1 LLC ------1 COMPANY NAME p-1 YIc'Kr;ere Plom- i-I z iciADDRESS ,00M CITY I LI). Yc rrr e)t-iF1,1 - I STATE alai tPI O -ys FA�)7�t0- 7861 CELLI50gS 3b437e241EMALI - - irg � 8 ( i ' jGat m • � • v �' R / /i- BlJll DING niz-sa T eM o � � � N