HomeMy WebLinkAboutP-20-1507 MAP: PAR c EC : y ock_ re 9 1.43!""LeS
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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1-- � CITY i—' 1- / ri r/Yi O (ter-4 i 1 MA DATE 7 /(o % 9 I PERMIT# gold-am-07
OWNER'S NAME /)/ G c) 1 J-P I
JOBSITE ADDRESS 4 Z �� P G Vf/'A rU D I< �t 4,(
POWNER ADDRESS r 5---0`3- I TEL �,7-7//7 IFAX
TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL U RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:El REPLACEMENT:0 PLANS SUBMITTED: YES❑ NO®
FIXTURES 1 FLOOR-' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB l II _ [ .-- .L. -----L- ---J. I
CROSS CONNECTION DEVICE r, ,. -- J, _' i
DEDICATED SPECIAL WASTE SYSTEM _ : _ .-�� ' T = 1
DEDICATED GAS/OILISAND SYSTEM • (
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ilmi
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_DEDICATED GREASE SYSTEM . - � - �' �
GRAYDEDICATED WATER SYSTEM
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DEDICATED WATER RECYCLE SYSTEM r J__
DRINKING FOUNTAIN 111 jimicWom,
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Pig LIINffliwillin w ._ �'- ._
FLOORFOOD DISPOSER
/AREA DRAIN IM' . . �i11
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INTERCEPTOR(INTERIOR) I'
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KITCHEN SINK _ i � -. - _- �- �-
LAVATORY i�� '( r�I. U
ROOF DRAIN — �' ;� . t tr
SHOWER STALL um
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SERVICE/MOP SINK wi,,„=.,...`
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TOILET � -
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WASHING MACHINE CONNECTION NM
URINALI _SWUM WATER HEATER ALL TYPES
'__-_-=IF _ IIIIIIINI IRMA ia ; E
WATER PIPING t
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' _OTHER I � �- l�
MN,MEI
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 2 NO 0,
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY® OTHER TYPE OF INDEMNITY 0 BOND E
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 El
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 all Pertinent provision the
Massachusetts State Plumbing� Code and Chapter 142 ofthe General Laws. (fin/
PLUMBER'S NAME I�I ' 1 I r(n %> f -1 C_ �LICENSE# I�lfl T (1 SIGNATURE
MP® JP® CORPORATION0# 'PARTNERSHIP®# ILLC[3# I f
COMPANY NAME A( ( i ! Pr // ADDRESS rL �j �// / t/`iP
CITY I w --7. t I. NI 0 sA—41 I STATE I (, ZIP n 2 (e 7 ( TEL 77 y / 9/2 I
FAX I CELLI EMAIL 1-1-1 n e/ ./► . r R r �kn 1A/"t It ` i,t
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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_>!_ CITY ‘ �f
_ _V'..c. . .G f N. C)� MA DATE PERMIT#/,�L/J/�'?oD-00/�7
JOBSITE ADDRESS; /2 a t �
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co d t 2./)1 ER'S NAME d0 ,.? e Imo S I
GOWNER ADDRESS
it)TEL / --/ IFAX j
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL;] EDUCATIONAL J RESIDENTIAL J.
CLEARLY NEW:J RENOVATION:. REPLACEMENT:,} 1 PLANS SUBMITTED: YES J NO
APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER __I—s—_I.J— —_J_I:_____.1—J J J J_— __1 I I
BOOSTER I 1 I I t___1_1'�_1_J I I_I_1CONVERSION BURNER i. I: 1 I I I.
I- —J�_�—�'�!�`�
COOK STOVE L I _ t— - .— 1—I—J:— —j_I I 1—�_1—1
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DIRECT VENT HEATER I_1_1 1:. },_ I_1-_1_I_I 1 1 _
DRYER 1 t f -.. . .1__ ._. 1_ --1 1 i_—. I— I—1
FIREPLACE ._ I I. .._ 1. I _. . 1_I 1 1 .- I_J _.. I _ .__I I_.11
0 FRYOLATOR 1 I—J :�—I .... 1 . . .1 I _-I___I-.._._I�.1-_I
FURNACE
I GENERATOR 1_ .. . I 1 --
GRILLE i_ -- I I . ... 1 I ._...__1_J:_J:_1_1_I_ i:._ _I—__1
INFRARED HEATER 1 .. --t—J.-1 . .- —� '_1 —J __I—J_I—J
LABORATORY COCKS 1 _.! .. 1 . _ I _ 1 . I I______1__J_ 1_J_4_J
pMAKEUP AIR UNIT ' 1 . I I_____1I 1____I__„J • . I -i
kOVEN I i i I 1- I___LI 1 . i 1. 4I I J:�
POOL HEATER I 1 I. I._ . ...1 1 i.�J—_I�1 _ I, .....1_,. , -I i 1
ROOM I SPACE HEATER _
ROOF TOP UNIT „.I I I I 1 I -I .1 1 0IT r . ' 1_L 1
TEST I 1_ 1 1_.-___ �J _.I i - I I.- -_Li a ;
UNIT HEATER ��! I I I_ :_ : _J't '- a ' J,;1-: -: t.
UNVENTED ROOM HEATER 1 I i- i .___.i I S"'j_-�J - I---1 +_-
WATER HEATER -, / I-__J i I___I 1 I_____.1
I_._,f__I I _J_i
OTHER ; 1 I I . 1. I -1 f
OTHER ____ �1 1_ _ €.__ 1 I
I I _..__I ._ I 1-__1
L 1 1----1 I I—J I I__ _.1�1 I�J _i I-(
I 1 I 1 I I 1 1. ! 1 1 1 1
t INSURANCE COVERAGE 1 _
tI have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 10 NO ,_!
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY _I BOND i_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 waives this requirement.
CHECK ONE ONLY: OWNER ._I AGENT J
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. sJs-
PLUMBER-GASFITTER NAME L� et,p L I LICENSE# y € SIGNATURE
MP ___I MGF �1 JP-_-.:IJGF'- LPG' __I CORPORATION']#' I PARTNERSHIP E# LLC _(#
COMPANY NAME'S < < t �-'( j ADDRESS ( 1
CITY W 7:1-h d _
STA ZIP �)7�73 iTEL -7 ��D �/2
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FAX I CELL: !EMAIL-
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