HomeMy WebLinkAboutBldp-19-005725 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY/TOWN§. Y/4 D(4 MA DATE PERMIT#/'/12n / CV57`gS"
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OWNER'S NAME z.L{ s'!L'�-` icz s
JOBSITE ADDRESS �02 in) �h a r���' R �'
OWNER ADDRESS krAg TEL603 (i/ /.3 l FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL L '
PRINT �-,/
CLEARLY NEW: El �L�
RENOVATION: [V 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
FOOD DISPOSER
FLOOR/AREA DRAIN •
3. _
INTERCEPTOR(INTERIOR)
KITCHEN SINK •
LAVATORY ; APR ()`) 2019
ROOF DRAIN
SHOWER STALL ;__ i N C� U PA RT N,1 nr
SERVICE I MOP SINK '-_-.
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
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
LIABILITY INSURANCE POLICY ❑ 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 tha re on this permit application waives this requirement.
CHECK ONE ONLY: OWNER AGENT ❑
SI TUR WNER OR AGENT
I hereby certify that all 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 Qertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,Kra
PLUMBER'S NAME /IN 61 -' 'k-t 6D I125 LICEN.'� • IG ATURE
MP❑ , JP a CORPORATION❑# PAR - HIP❑# LLC❑#
COMPANY • ' / ADDRESS/,S-,,a/ A/11•<c/e) c
CITY PC.�'il itl/ STATE, ZIP 0026 s r TEL$ 0 8 f S 5-0C. >I3
FAX CELL EMAIL
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
=1111r-gMA DATE PERMIT#j1�9'7�
CITY3f� AgintJ141'�
JOBSITE ADDRESS Tp2 /j//p.4 Cr , /L/ i'( OWNER'S NAME Z,/C/FIIi/a /
1i�!ijA,pLGL9 t J�G( TEL66 g�3 / /33) FAX
G OWNER ADDRESS ,"aZ �'
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ �/ EDUCATIONAL ❑ RESIDENTIAL Q/
PRINT �,/
CLEARLY NEW: ❑ RENOVATION:[2 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 APR 09 2U1S
ROOM/SPACE HEATER 9 '
ROOF TOP UNIT ;a.�t; ;- :::PARTME-.err
t ,
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑ NO 2/
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 La t ure on this permit application waives this requirement.
CHECK ONE ONLY: OWNER AGENT ❑
SIGN OF OWNER OR AGENT
I hereby certify that all o 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 co fiance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. .�.
PLUMBER-GASFITTER NAME TO n/ Pik s 6 4-- 6 a 11"f 6 LICENSE# 17 I`� SI E
MP❑ MGF❑ JP a/ JGF❑ LPG'❑ CORPORATION ❑# PARTNERSHIP❑# Lc❑#
COMPANY NAME ADDRESS -Jr '12fl h1/1V r Clai►.>"(21(92 -
CITY ..(�y(,.gt,D
STATE a ZIP 002‘.3 7 TEL ,�A� Sys CoZ )`3
FAX CELL EMAIL
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
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