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HomeMy WebLinkAboutBLDP-18-001948 5,, , rAP: I°t�4e e C : . 130 �, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' —(- CITY 3.` / A LL O`er'% I MA DATE 1-74-71-1 PERMIT#i&-OP-I f-ad P6r JOBSITE ADD SS Ili f 1 hfv/s Ai) I OWNER'S NAME 0 -pJ,P fl O I p OWNER ADDRESS I TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 15" PRINT CLEARLY NEW:❑ RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO[] FIXTURES Z FLOOR-. BSM 1 2 3 4 5 0 7 8 9 10 11 12 13 14 BATHTUB —NM M,It'—'M MIN M N NE _—--M- CROSS CONNECTION DEVICE MI MIIIIM MIMIM OM II 11. 111 AM MI I•IIME 1111.INKMI Lam Id.L9���3►:g5=MJUE,!1♦MK NM—!ono tit ,i 'tom ow onirp mu row—;j-1Sok DEDICATED GASfOIL1SAND SYSTEM NM MI 1MMII MN;—tilt M PM M MIK Mill.MEM M;PIM;ME DEDICATED GREASE SYSTEM NMI AM NM NS AIM .i•MN_':I1111.NMI MINI NM ipin MIN=5 DEDICATED GRAY WATER SYSTEM flit 11111_.111.MI-lig N'NM.I11.1.,O' NW M'I:'MI DEDICATED WATER RECYCLE SYSTEM MK MI ON IMMII u poi'mom'won o It ropo—'woo'a. DISHWASHER NM Win_Ik illi.i1111.pm ormow,m no ow mu no olow w DRINKING FOUNTAIN 1110._INN,NM ilai,!!Wm M:M �����NMI���(• �INN Owl I�rumuC FOOD DISPOSER �MII. FLOOR 1 AREA DRAIN •MN$111111 MN 011114 MI MIN NMNM NM.1111 NMI proff mu um pm KITCHEN SINK MIN war`i•MI WM N![.I1111..III SIM 1®I NIB 1111111 MK_tom M: LAVATORY —rilloillik ,PM.P_ --am p min i=",—',—, ROOF DRAIN nor OM;MI;IMO MR i NM MN_Ma'.MIR,.PM[it Mil MIN SHOWER STALL NM inik`iiiiiiiR= ,Om moo AK olio N(tHii><tnil MIN(lIJ11111WI SERVICE 1 MOP SINK Om nor AN ilulir Nor''poi pop poploorposiMM<ono pri.NOB TOILET moilVill;'Int 1111.1.1111111111'NM;— WA 1111 NIWM NOR Mr URINAL —WI Wail WOCIOP011nit'opor opt kiwk J/.R rill; WASHING MACHINE CONNECTION prop opo,MOO NM II.WN W!OM�-IIWW:Pm OM Mg mot Mt WATER HEATER ALL TYPES MI MP=I'M.NM MIR N MI M MOM EPP,OM P-ram"M' WATER PIPING WA�':����.�.�NM SR� - '- i_�' OTHER N IMAM ;'�_' IIIIIMIIIIIIIIIIIIIINIIIIIIIMII RUB WM PM - tom UM_�NM�! 1111. 1111111111111181.1/11110111111111111111111 flit MOB I—--CAM MO M—L - '••OM Mit proCloor opo MI MIN MN BM MIR OM NO mil pm 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 E 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 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 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 prance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. •PLUMBER'S NAME, /9_! (ii,SS"!f/1/C' I LICENSE filk Wi' SIGNATURE MP"JP❑ CORPORATION❑#I /(___ IPARTNERSHIP❑# LLC❑# COMPANY NAME C_C-,, f,�f'�i�„`'e'.. I ADDRESS (*r447AAJ 6c- I CITY S )44./),,Gbtr,rA I STATE 144,1 ZIP ©- I TEL.fib !-7s I MAIL FAX I CELL l �)-,5 "�3�/,�-E I ell' , :5() ./ D � � O I .: flu _,I. . MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS FITTING WORK I' 5 1t eA e" ' ` • MA DATE d PERMIT#/'ri^✓* / pa/e/W - . CITY JOBSITE ADDRESS qq-11Id,,//���`�f .6...- y AN OWNER'S NAME 4V G z s Ago yffitG OWNER ADDRESS ' I TEL FAX —. TYPE OR OCCUPANCY TYPE COMMER AL 0 EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION: , REPLACEMENT:0 PLANS SUBMITTED: YES 0 NO 0 APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 • 11 12 13 14 BOILER BOOSTER CONVERSION BURNER — COOK STOVE _ Ir , DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE / GENERATOR GRILLE —' INFRARED HEATER LABORATORY COCKS - a _ MAKEUP AIR UNIT ` OVEN ! :) !% i POOL HEATER —_ ROOM I SPACE HEATER 7� ROOF TOP UNIT '. CiCkt- 135- TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER / r OTHER H -- INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES at4L ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG5 BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [}------ OTHER TYPE 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 0 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 accu Pto the tine best stp o s my of and that all plumbing work and installations performed under the permit issued for this application will be in corn •Massachusetts State Plumbing Code and Chapter 142 of the General Laws. _ PLUMBER-GASFITTER NAME Al a4jc.he LICENSES 'VIC- SIGNATURE MP 02- GF❑ JP❑ JGF 0 LPGI 0 CORPORATION 124 3014, PARTNERSHIP 0# Lc 0# COMPANY NAME ad,Mgratc rt Z a`T ADDRESS 8 EV 614.4H QCI �,/&wit,l� STATE 1�6a ZIP 0 a.[e 64L TEL CITY S_ ! FAX ,fib cc(6J-70 CELL 7 G- 6 EMAIL c't i 4ivic cad Az ���L- o Q