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 /
•
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