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HomeMy WebLinkAboutBldp-19-004802 ** MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _ 7-— y CITY SOUTH kikttvtr.rTl{ MA DATE 1 12.\ 1 \`( PERMIT#/7A0,1)19 _ a 6 JOBSITE ADDRESS aq 12.41MmulzA M1 OWNER'S NAME Pki.. icsik,s wat MM1Ty0'J 1C POWNER ADDRESS TEL S0 'j :).'11- 245-31 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[a PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO Er FIXTURES 7 FLOOR-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE , —__1 DEDICATED SPECIAL WASTE SYSTEM _ DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM - - a DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER _ _ DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) • KITCHEN SINK i LAVATORY ROOF DRAIN ;7:- --`_ 1 SHOWER STALL '�� '� E SERVICE/MOP SINK Fa ��1 i. TOILET I ` Fa� 21 E 1. URINAL L 241 . ' WASHING MACHINE CONNECTION r WATER HEATER ALL TYPES I3 u i LV I {'ARTMENT n�. __ m — WATER PIPING _ OTHER ii INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES'NO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i OTHER TYPE OF 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 l' Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I I hereby certify that all of 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME 1(...NAEL it- 1)3 NO J to..i LICENSE# 15*A3 . SIGNATURE MP 2j/ JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC 0# COMPANY NAME GekPEt..►t Qk.k.s ,-lt, c NQ►AT‘NS‘ ADDRESS 135- cdkplAANI 5 MAU 4-0. CITY S. IttlimcksN STATE MA ZIP OStCG A TEL l i K 1 t 4 - 1$`1 4 FAX CELL EMAIL LPQEWIdv0Iv nit 6WCSL4•MA06_• CON 1 0 ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No �f THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ i�i!YT )k i `�� pz_& FEE: $ PERMIT#Z/C1/ C>IAZ /k / PLAN REVIEW NOTES ` " 7/// _�_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK LI .�i-0: �/� LIB = ;1_.;6�' CITY 50 U'CN k(d'cJL.Mc,6TIA MA DATE 1 9.\ 4 PERMIT# eLdb/7-00 WO j JOBSITE ADDRESS Z.L\ tAt to09 Pt\1E OWNER'S NAME kL ,i1/44Jt. iMkcYlo n( GOWNER ADDRESS TEL S, - 2,A1- a5 3c-1_ FAX TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL["I PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: RI PLANS SUBMITTED: YES❑ NO 6- APPLIANCES 1 FLOORS-4 SSM 1 2 3 1 5 6 7 8 9 10 11 12 13 14 BOILER __I BOOSTER _____I CONVERSION BURNER COOK STOVE ( DIRECT VENT HEATER i I DRYER FIREPLACE I FRYOLATOR FURNACE GENERATOR GRILLE I I INFRARED HEATER y I LABORATORY COCKS S C " Iii E D MAKEUP AIR UNIT _� OVEN i 6 POOL HE?,TER • 2 1 20 ROOM I SPACE HEATER I ROOF TOP UNIT L. -.� y1.,_ -- B U i L D I !. 4�CT TEST _. Ely UNIT HEATER z " UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE ,_._,� I have a current liability insurance policy or its substantial equivalent which meets the requirements of IUIGL.Ch.142 YES Ly"NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE.BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY V 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 waive::this requirement. CHECK ONE 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 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 Pertinent provision of the i `'` Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ..4(440era PLUMBER-GASFITTER NAME M1/4C-' L �64°iAa" LICENSE# (51-Vi 3 SIGNATURE MP 4/I MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME C SOC M 01-iatAc jCs £. i12VVVVY." ADDRESS 135-- CikT/%1 1 stAA-LA- 4-0. CITY S. YktM 4T STATE At 4- ZIP d 9ICC 4 TEL '1 i A-5y -1814 FAX CELL EMAIL Chi-v.MflF QCuW‘tSVSG(4 ALA WO. CON\ ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ f4/11/k/ 6w, FEE: $ PERMIT# PLAN REVIEW NOTES te(4 7 / • v