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Home My WebLink AboutBLDP-20-000480 fl MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK `K =1 E-r- CITY \ wt c. '-t' MAN DATE 7 d 3- l 9 PERMIT#&op o10 # V JOBSITE ADDRESS J CI e rlr�- d , OWNERS NAME llay CYl POWNER ADDRESS 5cd01 e TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIALP" PRINT �,/ CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:L' PLANS SUBMITTED: YES❑ NO❑ FIXTURES Z FLOOR--+ BSIv1 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 LAVATORY �� ' V ROOF DRAIN . Ikt SHOWER STALL / . SERVICE/MOP SINK TOILET URINAL j 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 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POUCY 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 1' Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ F:--_ 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 co lia ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. L/. PLUMBER'S NAME LICENSE# )50�I-. SIGN TURE MP JP❑ CORPORATION[!111 PARTNERSHIP❑.# LLC❑# COMPANY NAME T ec.r ?L 4t&(c 1 h� ADDRESS L J Li 0I 1I S 1 �cr CW Q _ rJ ` , / CITY . to r UP STATE bJ( ZIP h y1- TEL d 23 7 .3Se`7 FAX CELL 5 ti f%t . EMAIL i V Gsr IfseVil1e (2) Q $ t 4%1 G 4 I/ 4/ell ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES j1 7/?://?) '- 'i 1671_ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK `` , s 1 CITY sit' m 0 kbth MA DATE 7 wa g 1 9 PERMIT# ; *00a7 JOBSITE ADDRESS i t 9 Oe,r If u)r lv_ ,J. • OWNER'S NAME 'Pare �� OWNER ADDRESS G a a TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL gy.---- PST CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: (.. PLANS SUBMITTED: YES❑ NO❑ 1 APPLIANCES 1 FLOORS—' BSI 1 2 3 4 5 6 7 8 9 10 11 12 1; 14 I BOILER —� BOOSTER I I I CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER ! FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE ' INFRARED HEATER LABORATORY COCKS . MAKEUP AIR UNIT OVEN i POOL HEATER ` Q ROOM!SPACE HEATER I''_- 1,i,.., ! ROOF TOP UNIT TEST UNIT HEATER INVENTED ROOM HEATER WATER HEATER OTHER _ 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 ❑ 1 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. I I CHECK ONE ONLY: OWNER ❑ AGENT ❑ 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 accurate 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 compile ce\ ith all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. `1t14 1 PLUMBER-GASFITTER NAME 1-(� ' L w i l (V LI IJSE'# SI NATURE ct MP i MGF❑ JP EI JGF❑ LPGI ❑ CORPORATION #F a PARTNERSHIP❑# LLC❑# COMPANY NAME �1 G1c1-2 al ) I ADDRESS ,l 7 1 (,f.)l /Lao 6-WA- P 3 • CITY V Oa tM 6 L ±V) STATE rIC 4, ZIP C)2 1,4 `7 TEL 5 Oaa 37 3.5'2 V FAX CELL 5 (LIP e._ EMAIL ' ?' `>� • -/eJJ fT ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# • C '14 (_.- c PLAN REVIEW NOTES f