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Home My WebLink AboutBldp-19-004802 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 3--7titr=y n n�%n __ CITY So�T\� \Iff 7Al tv\cQTI{ MA DATE �. I g\ ( \cc /7 PERMIT# i�/ 9' 19GSg po'lC JOBSITE ADDRESS �� A`(MUart1 �V'E" OWNERS NAME MtT �[�ICSe.,J OWNER ADDRESS TEL SOP ?.`k1- aS34i FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 2 PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMI I I ED: YES❑ NO Er FIXTURES T FLOOR-F 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/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER • DRINKING FOUNTAIN FOOD DISPOSER FLOOR!AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY : ROOF DRAIN ��1 i -E rot SHOWER STALLp�, • SERVICE/MOP SINK TOILET I FEB 1. tb�� • URINAL _ L WASHING MACHINE CONNECTION - -�-- TTJ GA' ul WATER HEATER ALL TYPES u ? �^T^.�. 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 0 i 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 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 ikA CLNEE\, it— 1=01►OV LICENSE# 15'A k3 . ofeidgit SIGNATURE MP 2/ JP❑ CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME C44E%..lkpF f kkirA 1).1t, c kiPATk.S S ADDRESS 13S OVP-ON fl S MALL_ 4-0. CITY S YOntivipLITN STATE MA ZIP OWL- TEL -9`1 - - 1$41 FAX CELL EMAIL CAEwl11p- M6%4G tlt• CoN\ ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ l�i��7 v / 'k c �� FEE: $ PERMIT# PLAN REVIEW NOTES /—gt"( 7// C)1*/77. A • ' ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ` _,,r CITY SC)1'iN '(r4vf1Mc.Vc k MA DATE ')-1 °.\ PERMIT# /L�LS �4t�WO j JOBSITEADDRESS VA tA1,400h i OWNER'S NAME AIE-V-,1*1t. tMvcft_o\iaL G OWNER ADDRESS TEL StIE- 3.y\- FAX FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL[� PST CLEARLY EAR Y NEW:❑ RENOVATION: ❑ REPLACEMENT: [✓� PLANS SUBMITTED: YES❑ NO 1'.1 APPLIANCES FLOORS-I BEN 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER -I BOOSTER CONVERSION BURNER, COOK STOVE ‘ DIRECT VENT HEATER l DRYER FIREPLACE ' FRYOLATOR FURNACE GENERATOR I GRILLE INFRARED HEATER y I LABORATORY COCKS c '€ i i, E 0- 1 1 MAKEUP AIR UNIT �•��i�'® i OVEN �.. V ._.._..� �. y� V i POOL H EATER ________, , i FFB 2 �- 2015 La i ROOIJI;SPACE HEATER ROOF TOP UNITL.._ �BUI_,DI me TEST - UNIT HEATER ? UNVENTED ROOM HEATER I I WATER HEATER OTHER I I 1 INSURANCE COVERAGE �.,� I have a current liability insurance policy or its substantial equivalent which meets the requirements of IUIGL.Ch.142 YES Ii ►10 ❑ 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 ❑ I 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. I CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT •`1-• 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. i L.0 PLUMBER-GASFITTER NAME MkC- L bo t'So J i (SLAY:3 LICENSE#� (SLAY SIGNATURE MP I/MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION❑4 PARTNERSHIP❑it LLC❑#4: COMPANY NAME G ui,t)E {'a_L,rkhwiC: . ik42A \ & ADDRESS \3S- Ciffliall S,Ntik ., O. CITY S. 110c(2 ,k<iT STATE tM Ar ZIP d aCC-4 TEL 1"1`\-5'04 %8`14 FAX CELL EMAIL C1t�i-vS‘OV OCLIrA(S$TSG(2 60. (OM ------- ------- -------------- ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ 75t/111<k/ fie, CX FEE: $ PERMIT# / `!� J PLAN REVIEW NOTES `— ��e(4 / r • • i •