HomeMy WebLinkAboutBldp-20-001874 ckc c e_ . I 1,0 07--,91-
MASS CHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
lL 1 /�b O� IAA DATE PERMIT# 4P- /o
WCITY / , A �j %�BSITE ADD ESS ma gj OWNER'S NAME , l 6L/�
JO
OWNER ADDRESS 1 M "�/ ^e ® TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL
PRINT `CLEARLY NEW:0 RENOVATION:❑ REPLACEMENTS PLANS SUB ITTED: YES 0 NO 0
FIXTURES Z FLOOR BSM 1 2 3 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOILISAND 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 I 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 12( 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 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 ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
r •
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the bestt off my my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in complia it all Peru ; . o ///
the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
C G r ; (\i ecl e I I LICENSE# F'�y(� STATURE
PLUMBER'S NAME
MPM JP 0
CORPORATION❑# PARTNERSHIP 0# LLC❑#
COMPANY NAME C c'r i r R ecl e 1( S
an ADDRESS 7d i n 6t-cee }
STATE I !� ZIP C l Co TEL 5CG s_ `I ?� Co 3CP
CITY OS�erv' i112 �
FAX
CELL EMAIL
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WO-
•
,tk,". _- w PERMIT# -� 7'
= _'�, , L j . MA DATE 11J VJI I f 4
z ter CITY
' — ����/ ��� m OWNER'S NAME
JOBSITE ADDRESS ��
G 3
FAX
TEI
OWNER ADDRESS /rJ '.
� I RESIDENTIAL
TYPE OR OCCUPANCY TYPE COM ERCIALD EDUCA IONAL ,
PRINT PLANS SUBMITTED: YES N0
CLEARLY NEW;0 RENOVATION:� REPLACEMENT:
D
4 5 6 7 8 9 10 11 12 13 14
APPLIANCES-1 FLOORS—, BSM 1 2 3 y��WllitlIMIWIN
'
BOILERWIIIISWWINOliii i
�I
BOOSTER
CONVERSION BURNER =�
COOK STOVE
11111111.11.1.01111.
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR --�,
FURNACE
WOW . ,i
WIIMMtillitilliWiiii
III
GENERATOR
GRILLE WIIWIWKWIMIWIEWILIMINNIMMiiii
INFRARED HEATER WIWIKIIIEWIIWIIWBIIINIEWIIIWIIWIMEMMMFMIM
LABORATORY COCKS IMINIWIWIIIIIIIINIMMWIWinatiliiiiiiiIMMMI
MAKEUP AIR UNIT MINIKWIRWIEWIWINNEWINIIIIMINNEMIIIIIIMINEM
OVEN IIKIINIIIIIMMMIIIIIMMWMINIIIIIIIIMIM
POOL HEATER IIINIIIIMIEIIIIIIIIKIIIIIIMNMINILIIISIIIIIIIIIIIIIIMUIIIMIIIIIINIIIIIIIII
ROOM I SPACE HEATER . '
C f,E
IIIII
ROOF TOP UNIT
TEST
UNIT HEATER WitillOWOMMINSMICIUNIIIMINIMMINIONIMME
UNVENTED ROOM HEATER
WATER HEATER
OTHER i
INSURANCE COVERAGE
I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 4 NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW BOND
LIABILITY INSURANCE POLICY 1/'' OTHER TYPE INDEMNITY
OWNER'S INSURANCE WAIVER:I am aar signature licensee
on this permit application insurance
nth s coveragee required by Chapter 142 of the
Massachusetts General Laws,and that my
CHECK ONE ONLY: OWNER Ei AGENT E3
SIGNATURE OF OWNER OR AGENT
t �•• •
he
I hereby tha certifyllplumbing
thing all wo r the
details k perfomed unde the submitted or
permit issued entered regarding
hisdapplicationpwi l be in com are pliaand accurate all Peo the best proviof my knowledge
and that all plumbk g / —
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `�_ ��
PLUMBER-GASFITTER NAME
LICENSE#1=1 S ATURE
MP in MGF JP 0 JGF 0 LPGI 0 CORPORATION 0#j
PARTNERSHIPD# _. _.J LLC Di ,.
COMPANY NAME: ._.. . �!' I. . I"... l�.s....,c��i.L.
fi Spn : ADDRESS, -775 . M.G I.n.... Scree ..
CITY C7 St-e r v !.Ile.. .._ .. . .... _... _ . .
STATE _MA ZIP' O a G `3._5.. TEL 50 S-....._1-1 d - Co.
FAX _.._...__.._.._._......_._.10ELL ._.............._. ..__.
EMAIL.. . . ....
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