HomeMy WebLinkAboutBldp-19-005630 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY I MA DATE 3.-_ . PERMIT#/ ' . --100 5610
JOBSITE ADDRESS // C ,Q I OWNER'S NAME e rc� cx '/`__
T r LI/L_C C I. 75596 '1TEL -g- -. z- -- — FAX i
P OWNERADDRESS ca c' JJ o 7 J� _-L1 — —
TYPE
OR OCCUPANCY TYPE COMMERCIAL'„ EDUCATIONAL 1 RESIDENTIAL 'TO- 77�/"//5
PRINT _ > �-Co 3 s T4c _
CLEARLY NEW: ._1---
RENOVATION:j REPLACEMENT: PLANS SUBMITTED: YES J NOrij
FIXTURES Z FLOOR-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
I r -_ -1_-_u - J fir__._ __1 ---1
BATHTUB � _
CROSS CONNECTION DEVICE L 1_ T I I' 1,7 1_ i _ l
DEDICATED SPECIAL WASTE SYSTEM , ! E L i _ , _ `— I _ t; _ u 1
DEDICATED GAS/OIUSAND SYSTEM -17 _ —1 T__„ i+ li t t� ; �1- I
DEDICATED GREASE SYSTEM iY— _v _ 1 L -��
DEDICATED GRAY WATER SYSTEM ._ `- 1�- _ I- " , i 7
DEDICATED WATER RECYCLE SYSTEM ____ 1. r — f' _ ` _ _ I
DISHWASHER _ .1'_� I_.___I_��'T_ nT _ 1
DRINKING FOUNTAIN _ 7 ._._ 1 1, �- l
t _ i t t b___ L 11 l_
FOOD DISPOSER l' t i i - L u l i
FLOOR/AREA DRAIN r I; i -1
INTERCEPTOR INTERIOR ; - 1 L __
E
I.
KITCHEN SINK ' 4_ L___.. __ .li ___17 J _. -__ L L_.�!__ �, l
LAVATORY Ji -� l _-7 1 ( L.-� 1 __I -�-1
ROOF DRAIN I -1- -1, -1 __ �� I f ! i - _. 1_�
SHOWER STALL 1-- -- �-I 1 _--_._ , .- i t i
TOILET 1- -z _.4 ^. (€ _,. -- _ _�{
SERVICE I MOP SINK LI
-1 F
URINAL I} __ _- __ I- I; .___. I L L t___ �' ,
WASHING MACHINE CONNECTION -i _ �1 -' 1J --v. I '
WATER HEATER ALL TYPES
L
nilLst
fi __.. � ,_._._ ._ ter" i�.._ ��e�--
WATER PIPING L 1� 1 _ L _ L L I i! i _ t:
OTHER __.i'
' 1 1"---1
- IL- L-- - _ L .1,— _ _ - ° _ !' ' 7�
u
I 1.--- L -I i, 1.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirement MRt-Eh.t42i L'ES . = NO
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOIX BELOW "af
INSURANCE POLICY._. OTHER TYPE OF INDEMNITY BO D 4. i-k I! i lit?
LIABILITY SU ,�,
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage V4140042 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER AGENT Li
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 ._- !LICENSE# . SIGNATURE
4 JP CORPORATION # "PARTNERSHIP'
MID -II-1- .`# LLC _1#
COMPANY NAME. ADDRESS
CITY 'STATE ZIP , TEL
FAX . CELL EMAIL
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
A-30-i CITY: 5c (J IA l e 0 MA. DATE: 57Z(0/f PERMIT#/ -0
JOBSITE ADDRESS: I 70 C In T//C h G o C' /D OWNER'S NAME: 7J? 7`e �3 P
G OWNER ADDRESS: 5 /7 47)4
04-C i(Y '/,3C) ?/(2 /. FAX:
TYPE OR 5 rD w�1 ✓`) �9
OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 0
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:121 PLANS SUBMITTED: YES❑ NO gJ
APPLIANCES11 FLOOR— Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCK
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
TEST R E E
UNIT HEATER _
UNVENTED ROOM HEATER 3
WATER HEATER / APR 3 2(1 Y ' V V
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 have checked YES,please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY [21- 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.
CHECK ONE ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
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/GASFITTER NAME:�'", t C►�n &ict 1'l c)J ( ic9p LICENSE#/ *Si SIGNATURE
COMPANY NAME: (f\k C Ci 0 t ADDRESS: (2_ CJ 3 17C 1 J f / 1./4
CITY: � - Gl T Aft STATE: "" , ZIP: G' Z60 / 3 FAX:
TEL:—7 7 (GO 7/ 2- CELL: EMAIL: )---1-1 A 51"J' •M rt c�P a D vV'V L l U M
MASTER❑ JOURNEYMAN LP INSTALLER❑ CORPORATION❑# PARTNERSHIP❑# ►v P LLC❑#
IT