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Home My WebLink AboutP-19-6305 cm or LC-v-4S MASSACHUSETTS UNIFORM APPLICATION FOR A PER IT TO PERFORM PLUMBING WORK �= CI MA DATE PERMIT#/ a917—G??63D1 JOBSITE ADDRESS 3 l,`1 I WNER'S OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY PE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES rfNO❑ FIXTURES 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/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 El C -E I V ED LAVATORY ROOF DRAIN / 4 SHOWER STALL - Va i 1 ?Uri • SERVICE 1 MOP SINK TOILET P RTi .EIv7 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 NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE E 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 JMassachusetts 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 ccurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complianc ' all Pertinent provision of the Massachusetts State Plumbing Code Code and Chapter 142 of the General rLaws. PLUMBER'S NAME ��bi'V PtI j" /i ,(J TQe6C/ ICENSE# `; W SIGNATURE MP ZAP 0 CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NA E ADDRESS 2 A ?`1C/W CITY / U )T4 STATEMA- ZIP vd7 3 TEL-So s 3' O ' `j FAX CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No 4 7/ jot & e,/ey THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ , 70 05E- ?,/f F FEE; $ PERMITitf-7//? PLAN REVIEWNOTE5 'c '7°1(07 126 . fe(Ve 7c� Diow-efETervip 07, e/ t r � -.'' MASSACHUSETTS UNIFORM APPLICATION FOR A P MET TO PERFORM GAS FITTING WORK lIP' MA DATE �� PERMITttt JOBSITE ADDRESS ' 4JNER'S NAME OWNER ADDRESS'' TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL PRINT NT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES 0 ❑ 1 1 APPLIANCES-1 FLOORS-4 BSM 1 ? 3 4 5 6 7 8 9 10 'I11 12 '13 14 1 BOILER BOOSTER _______I I CONVERSION STOVEVE DIRECT VENT HEATER DRYER — `�� FIREPLACE .- - — I i FRYOLATOR 1 FURNACE GENERATOR, GRILLE INFRARED HEATER -, , , Hi LABORATOR`(COCKS MAKEUP AIR UNIT OVEN Vt;`1( t i i, OM 1i POOL HEATER i ROOM/SPACE HEATER . p .:' ,';; ROOF TOP UNIT ___ TEST ... .-.. • • UNIT HEATER LINVENTED ROOM HEATER WATER HEATER OTHER i _ I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivale meets the requirements of EVIGL.Ch.142 YES 0 ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE -.BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ 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 valves this requirement. i CHECK ONE ONLY: OWNER ❑ AGENT ❑ I 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 acc ate 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 compliance wit ertinent provision of the Massachusetts State Plumbing Code and Chapter-142 of the General Laws. �G t PLUMBER-GASP - ERN LICENSE# `9 (, SIGNATURE MP ! u r�F JP JGF • 1 � PCI ❑ 1'ORPOP��TION❑�E PARTNERSHIP❑# LLC❑# COMPANY NAI - ADDRESS 254J7fokJ -P' 6g/44 CITY STATE ZIP 026173 TE 3 3$ FAX CELL �� ELL EMAIL s • . ,,, _. ,,,) L____,z. ...., ,, .\. , - ---_-_----_ - , -‘i,, _.; \A i '-.-- 2 ' a 0 2 `r, C r c b z t c y