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HomeMy WebLinkAboutBldp-20-000071 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK r --�— CITY � W1o,i) `1 MA DATE -7/)11 9 PERMIT#.I, P`�' 7'/_ JOBSITE ADDRESS ( I Oj R► 2 - S . YA/Lr4l001-1 OWNERS NAME p kCcA t��11.+1 ESL OWNER ADDRESS TEL 1270i-ficY -9M& FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:Egi. PLANS SUBMITTED: YES❑ NO • FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 B 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 - r - FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL ; SERVICE/MOP SINK I TOILET URINAL JUL71 . WASHING MACHINE CONNECTION WATER HEATER ALL TYPES I WATER PIPING I� OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 0 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ® 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 j 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 corn liance wt�rtinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBERS NAME LICENSE# i O t7SS SIGNATURE MP E. JP❑ CORPORATION 0# PARTNERSHIP❑.# LLC❑# COMPANY NAME ��// ADDRESS & ?6:1( 3 6 CITY /4//0 ,0 STATE /'�/i- ZIP (f2 L 7J TEL 5 4C- ' 36 Z -pl 5Z FAX CELL EMAIL -AI 44 ZQ ME. GAN if ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No /� THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ �"- ft Jy.l Z `j � - FEE: $ PERMIT it PLAN REVIEW NOTES 7/&//p _' . '~ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 4. O s. CITY W Wl G'I/T h MA DATE 7/ //1 PERMIT JOBSITEADDRESS (10S gl LCr S, yren'1a✓7►,1 OWNERS NAME pi CC O► I! ( $F Li GOWNER ADDRESS TEL S Gk 3 9 LI o'd. FAX TYPE OROCCUPANCY TYPE COMMERCIAL© EDUCATIONAL ION•AL PRIM ❑ RESIDENTIAL❑ CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: 2K1 PLANS SUBMITTED: YES❑ NO a APPLIANCES FLOORS-- B:M 1 2 3 4 5 6 7 ° 9 10 11 12 13 1 4 BOILER BOOSTER I CONVERSION BURNER i COOK STOVE - i DIRECT VENT HEATER DRYER FIREPLACE —~ ___II FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER i LABORATORY COCKS • t MAKEUP AIR UNIT I OVEN tr i POOL HEATER - 1 ROOM!SPACE HEATER ROOF TOP UNIT C /2 ✓ ^3 TEST -r(�s Q^ , UNIT HEATER UNVENTED ROOM HEATER 1 WATER HEATER —r- OTHER V INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of NIGL.Ch.142 YES ❑ NO ❑ 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 Laws,and that my signature on this permit application waives this requirement. i sl CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT J 71, 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 `k- and that all plumbing work and installations performed under the permit issued for this application will be in compile .with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `r.1 PLUMBER-GASFITTER NAME LICENSE# (o e 7 J— SIGNATURE MP 2 MGF❑ JP❑ JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME ADDRESS L-adX 37o CITY yA-AWtovilip4/Lo STATE / 'A- ZIP OZ J GTi— TEL G `3C.2 '06_CC FAX CELL EMAIL CJ4SyuzeM.G.FNE .!vfr ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ • FEE: $ PERMIT# 1 � (X /7`✓ /2 ( PLAN REVIEW NOTES