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HomeMy WebLinkAboutBldp-17-6075 z....:1._ /4/4/24/4c44_/ er7.— -__ -j— \ ;- ; MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK — e— CI i V MA DATE PERMIT# �_. JOBSITE ADDRESS )LticZ OWNERS NAME C7075 L.:j r POWNER ADDRESS TEL TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL�� EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ 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 T DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM _ DEDICATED WATER RECYCLE SYSTEM y • _ _ DISHWASHER _ DRINKING FOUNTAIN _ FOOD DISPOSER - FLOOR/AREA DRAIN _ INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SAY f) 1 SHOWER STALL SERVICE/MOP SINK )j TOILET eS ' URINAL . WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER I I 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 OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 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 waives this requirement. `-' CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT ' i I hereby certify that all of the details and information I have submitted or entered regarding this application are true and ac e 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 ertinent provision of the Massachusetts State PI bing Code and Chapter 142 of the General Laws. PLUMBER'S N ME /\i OMPACT° 1,00. SIGNATURE MP JP CORPO TION❑# PARTNERSHIP❑.# LLC # COMPANY ME ADDRESS /5 Ji 4E) CITY / t PA . STATE HA ZIP 02A 7 TEL FAX CELLO5 /XJ 9SMAlL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# 610 7 l w/51 PLAN REVIEW NOTES T2 � frLAW / MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ... cis i�� = CITY \/�J1'�Dl 7771 MA DATE /�1 PERMIT# &D -2S- �/3 Te I ��5� JOESITE ADDRESS OWNERS NAME .� GOWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE ,;OMMERCIAL[.- EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW: RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO 0 APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 , 8 9 10 11 12 13 I 14 BOILER BOOSTER _ j CONVERSION BURNER, COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE ! FRYOLATOR I FURNACE GENERATOR _ _ GRILLE I INFRARED HEATER LABORATORY COCKS --I MAKEUP AIR UNIT OVEN POOL HEATER • ROOM I SPACE HEATER I ROOF TOP UNIT TEST -. -- UNIT HEATER UNVENTED ROOM HEATER /' WATER HEATER /l� _ OTHER _ 1 - - I I INSURANCE COVERAGE • I have a current liability insurance policy or its substantial equivalent whi h meets the requirements of MGL.Ch.142 YE NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE CHECKING THE.APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 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 waives this requirement t. CHECK ONE ONLY: OWNER 0 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 acc the best of my knowledge `- and that all plumbing work and installations performed under the permit issued for this application will be in compliance wi 'nent provision of the Massachusetts State Plumbing Code- d Chapter 142 of the General Laws. U PLUMBER-GASFITTER NAME ...P LICENSE# /5/9 SIGNATURE MP ❑ MGF[I] JP JGF❑ LPGI❑ CORPORATION❑# PARTNERS IP 0# LLC 0# COMPANY NA E /771/6/9-17 / AL-11- ADDRESS �`�/� T/(/� CITY X/I f/rni- STATE MA ZIP TEL TEL FAX CELL EMAIL I�OUGII GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ 2/ FEE: $ PERMIT ft l)/I//7 PLAN REVIEW NOTES • — 4T t.