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Home My WebLink AboutBldp-19-001861 11 fig, tki✓41,00n s irk1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _1=tair _..,•: v CITYVPS( fac110 di-k________a__ MA DATE ser�a7SOZ PERMIT# P/9 JOBSITE ADDRESS Vni tl°� A n• OWNER'S NAME( *Q—.40 rei. _I1 POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:X RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES❑ N0 FIXTURES 7 FLOOR—+ BS1v1 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 FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) .. �e r5 . KITCHEN SINK 1 1-- .� LAVATORY + 1 • I ROOF DRAIN , �'z .1 ' SHOWER STALL • I SERVICE/MOP SINK s �� TOILET 4' URINAL ='� . WASHING MACHINE CONNECTION WATER HEA I ER ALL TYPES I _ WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YEE 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 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 tru nd accura to best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co lance wi P ' ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1 PLUMBERS NAME LICENSE#319-7 f . SI NATURE MP❑ JP%1 CORPORATIONo ❑�#- PARTNERS ❑.# LLC❑# COMPANY NAME i �.. OktZi (/`�1/Jea/)✓1 ADDRESSeA L i (� ) STAT�Z ZIP OW / / TEL sd�'✓ 7 0 73 CITY�,� ! I GT CIIJ FAX CELL LSqfie.--/ EMAIL 4-0 ( //z/ /&77 e-7Y • ,:;yv-vefrkie..77 - 17,//‘ -vg 0--7d oy-/ po/d (2P 2/ip,//.9/ �-v!ti ' vim' 4 -(a g' I NO' (� �� /(2 ��G/ ti '; MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK `IMFji: _ CITY IviA DATE PERMIT5p-7— JOBSITE ADDRESS 4 , OWNER'S NAME C7IJ)IC Ofc/ 0)1 GOWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑PRINT RESIDENTIAL CL A_RLY NEW:A RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO j APPLIANCES:l FLOORS—I BSltn 1 ? 3 11 5 5 7 9 10 'I'I 2 1 13 1 BOILER M �� BOOSTER I BURNERCONVERSION INIILi; NM DRYER FIREPLACE _ FRYOLATOR -- w 1II, MAKEUP AIR UNIT \ ..,: dikil: ,, :., ,Au.-. , 1 OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT __ . UNIT HEATER UNVENITED ROOM HEATER i WATER HEATER IMI I 1 1 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 naives-this requirement. . w 'I 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 'L Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE# SIGNATURE MP ❑ MGF n JP ❑ JGF❑ LPG! ❑ CORPORATION❑It PARTNERSHIP❑# LLC❑## COMPANY NAME ADDRESS I CITY STATE ZIP TEL FAX CELL EMAIL if \‘A ‘c '.. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK P s' `=� y CITY W- 5) ai IMO k MP, DATE (Par 4 J d O// PERMIT# /✓ 46--/r'Ir JOBSITE ADDRESS I f igk G1 coi OWNERS NAME C)1 Fki_ei &__'('01i GOWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO' APPLIANCES 1 FLOORS—h BS1v1 1 2 3 4 5 6 7 8 9 10 11 12 •13 14 BOILER ---1 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER _ l DRYER FIREPLACE FRYOLATOR FURNACE — GENERATOR I GRILLE INFRARED HEATER LABORATORY COCKS -- MAKEUP AIR UNIT I OVEN d G, `�_ POOL HEATER { ROOM I SPACE HEATER 1 MAR )5 -.O 1 ROOF TOP UNIT + 1 TEST i 3`'3l_D.IN(� D PARTM' N r UNIT HEATER ' - LINVENTED ROOM HEATER WATER HEATER OTHER ,/ e e Old& ouh J INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW • LIABILITY INSURANCE POLICY 't 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 L I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the be of my knowledge �� and that all plumbing work and installations performed under the permit issued for this application will be in compii ce with J Pe ' en rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE#Syr/ 'IGNATURE MP❑ MGF❑ /JP COMPANY JGF❑ LPG! ❑ CO .PORATION❑ F ,�J PAR NERSHIP # LLC❑# NAME , , J P vit lADDRESS /j �/71Pd/J D a0>e /3) CITY L/v Oarnigl C k STATE m ZIP / TEL 6-0F`'-776 0.`G 3 FAX CELL EMAIL 004.c40'3 r l ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ /?‘9/- Q/ °Z (- FEE: $ PERMIT# j// / PLAN REVIEW NOTES rp,-07fre, cyi _,R42. 1 A