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Home My WebLink AboutBldp-19-005992 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK WIJIM lit -� CITY Q I/il ) MA DATE 11/6 PERMIT# &/9P/ 9' co cF49 , JOBSITE ADDRESS e7 / 6Jia tL (J1!'L1 OWNER'S NAME Bidei ,1 OWNER ADDRESS W. 1Q../Y n/- TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:El RENOVATION:❑ REPLACEMENT% PLANS SUBMITTED: YES❑ NO El 7 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/OILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/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 5. 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 that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER El AGENT El 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 complia ith all Perti rovision f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ) PLUMBER'S NAME C- r e LICENSE# 'g SI ATURE MPIN, JP❑ CORPORATION❑# PARTNERSHIP❑# Lc❑# COMPANY NAME C c,r t r R ect ell t Son ADDRESS 7 7 cs i"1 ; r1 S t're e 1- CITY GSfier tie STATE MA ZIP 0 .aco5S TEL 5os-- H - c 3(r,5 FAX CELL EMAIL N I`ila � arCC ( : MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Z In/d CITY a/,r�liviin ( MA DATE Y/11/01 I PERMIT# P'7�9`-UI J •:G ,a JOBSITE ADDRESS I lace � i'i'L ZdA/ ',OWNER'S NAME /�GJ'/4j. , GOWNER ADDRESS N. TEI FAX OCCUPANCY TYPE COMMj/ItP1J1,Arf1 ERCIAL0 EDUCATIONAL D RESIDENTIAL PRINT CLEARLY NEW:0 RENOVATION:0 REPLACEMENT: 'IdPLANS SUBMITTED: YES Q NOQ APPLIANCES 1 FLOORS-• BSM 1 2 3 4 5 6 7 8 9 10 ii 12 13 14 BOILER - BOOSTER i L ,n ,,_ 4 s , �1 -- 4 CONVERSION BURNER Fx_ I COOK STOVE ,_ , — -- DIRECT VENT HEATER (______. si.. . I _ f_ #,__t€._ . . DRYER I �i 1 I i''. FIREPLACE � . FRYOLATOR FURNACE -� i7 GENERATOR 1_,- _ I, GRILLE - I I . INFRARED HEATER " E i i ` LABORATORY COCKS I:.- , MAKEUP AIR UNIT S � � . OVEN POOL HEATER I • ROOM/SPACE HEATER I I I 1 _ I it I ROOF TOP UNIT € I 9 TEST UNIT HEATER I . ..,il [ I �, �.-a�- e. i; i I ' i UNVENTED ROOM HEATER i : . 1 II _ - ` a< WATER HEATER I . I 3I OTHER � � � �� j , ...„ _., , , , ii.„„„, („,„ . . _ „ „ , I ` INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Et NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY a OTHER TYPE INDEMNITY Q BOND Li 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 0 AGENT Q 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 aaccu�rate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compli�r�, 'K Pt provi ' he MassachusettsState Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME 4 c,r I 5 , R. e d e II ' LICENSE#-8 -y ,1 S ATURE MPZ MGF ED JP 0 JGF El LPGI® CORPORATION ID I PARTNERSHIP # LLC 0# COMPANY NAME: C a r I 1= R i e d e I ( r Son J ADDRESS -7 7 S M G. i n S k-re e k CITY OsfierviIle I STATE I"IA =ZIP Oaco55 TEL SUSS- H S- - Co3Co,- i / FAX I CELL[ EMAIL � S