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Home My WebLink AboutGas Water Heater/BLDP-23-8533 - BLDP-23-8533 1425 a3trs MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ig_✓- CITY Wes+ ./a r on • MA DATE 5 -a,W-.13 PERMIT# SDP"L 3"y 5 3-3 JOBSITE ADDRESS b 6 ra ny It w 00 d 0 '' OWNER'S NAME G rt1' 1<0 0 5 S POWNER ADDRESS t;a v'h-c TEL/003-5`0S-_agS8' FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL g., PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:13 PLANS SUBMITTED: YES 0 NO 12 FIXTURES 1 FLOOR-+ BSM 1 2 3 4 5 6 7 J 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM _ DEDICATED GREASE SYSTEM _ DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM ' _..__ DISHWASHER • r _ DRINKING FOUNTAIN J FOOD DISPOSER . FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) - KITCHEN SINK i _ LAVATORY r D •ROOF DRAIN ,v SHOWER STALL `� c ZD SERVICE/MOP SINK . ' 2 ill-'2 4 20�. TOILET ‘ URINAL WASHING MACHINE CONNECTION1 WATER HEATER ALL TYPES 1 o 1 '� 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 J4 NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 1 OTHER TYPE OF INDEMNITY 0 BOND 0 f 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 0 AGENT 0 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 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. *//‘( '' PLUMBER'S NAME LICENSE# ?:a7 OsT SIGNATURE MP 0 JP L7 CORPORATION 0# PARTNERSHIP❑.# LLC 0# COMPANY NAME Tock Kci ru. P woo, 4n5 ADDRESS 3 t tl 1 d 00 may Rr1 ' CITY 5• YO rich STATE irn 4 ZIP b a io q TEL FAX CELL 508 •6A'S S6 Sl EMAIL 3 Kant t�-{ S e yA)notl G7w' • ?M'' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK e` 1 ? CITY W CS f }l a r rn • MA DATE May a1•1 d a 3 PERMIT# ll�P . %3 -f�S33 JOBSITE ADDRESS (L 6 'Tang i•c W®c ci D r • OWNERS NAME 41-v K0 ._S t` S G OWNER ADDRESS S v„-e` TEL b 6 3 " So 5-a9SFf FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL �� PRICLEARLY NT ❑ RESIDENTIAL IX NEW:❑ RENOVATION: ❑ REPLACEMENT: [i PLANS SUBMITTED: YES❑ NO A APPLIANCES FLOORS-4 6Siul 1 ; 5 6 8 1 BOILER 9 I_ 10 'I'I 12 I � BOOSTER - -___I CONVERSION BURNER I COOK STOVE I DIRECT VENT HEATER DRYER j FIREPLACE FRYOLATOR FURNACE GENERATOR Li GRILLE INFRARED HEATER COCKS MAKEUP AIR UNIT J OVEN POOL HEATER _____I ROOM!SPACE HEATERI 4 , ROOF TOP UNIT ; ' TEST f, c �°UNIT HEATER \ . : c 23 UNVENTED ROOM HEATER Z _ I t WATER HEATER + I MENT OTHER pF_1aAR gL;tplN __ , II INSURANCE COVERAGE ! I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ;I] NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW• ❑ LIABILITY INSURANCE POLICY Eil OTHER TYPE INDEMNITY ❑ BOND ❑ 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. 1 SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ 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 s and that all plumbing work and installations performed under the permit issued for this application will be in compiianc with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4t PLUMBER-GASFITTER NAME , LICENSE# aa75--3' SIGNATURE MP❑ MGF❑ JP ® JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC # COMPANY NAME A cic IZ a►n c. (Ze r L it a --ivy ❑ ADDRESS 3`/ e_oid try),k _2I_ ' CITY_ S V arm O u A STATE irnU ZIP a Z 6 6 9 TEL FAX CELL_SOF( Ink_ - S0S,‘ EMAIL ( KQNCP Li.5- YnhoO" C't+"i