HomeMy WebLinkAboutBLDP-23-8485 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
_`_17 y CITY Y 6're tti d? MA DATE 5-7(ria-6.13 PEFO& - 73 -d 3?
JOBSITE ADDRESS / D 9 Q vur7,e r ma S7c r RD' OWNER'S NAME S(e 4n r14,,si
J
POWNER ADDRESS 5uwtt° TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCA ONAL ❑ RESIDENTIAL❑
PRINT
CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES❑ NO 0
FIXTURES 1 FLOOR-4 BSM 1 2 3 4 5 6 7 B' 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 •
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR 1 AREA DRAIN _
INTERCEPTOR(INTERIOR) _
KITCHEN SINK _
LAVATORY • ,
ROOF DRAIN
SHOWER STALL •
SERVICE 1 MOP SINK fjChB
URINAL TOILET f'fj .,./.57)
L1m
URINAL _ / 1
WASHING MACHINE CONNECTION - '
WATER HEATER ALL TYPES f - ;.y __ __,
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
LIABILITY INSURANCE POUCY I OTHER TYPE OF 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
1 Massachusetts General Laws,and that my signature on this permit aptalication waives this requirement.
• CHECK ONE ONLY: OWNER 0 AGENT 0
Z. SIGNATURE OF OWNER OR AGENT
L11 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 com lance with all Pertihlent provision of the
Massachusetts State Plu22mbin Code and Chapter 142 of the General Laws. D'�//,hyr1
PLUMBER'S NAME r3 G w 'j-- LICENSE# a-cf 3-K SIGNATURE
MP 0 JP Ltr!' I CORPORATION 0# PARTNERSHIP❑'.#n LLC❑#
1>6h 5 eLapy�ba - We7' ADDRESS S q-1- B W 4j Ptv�t l(
COMPAN NAME _
CITY Pe-AN s STATE In ft ZIP 0-431r— TEL
CELL EMAIL t✓f I Lia S 6 1 1 C_I(JV l� a M
FAX 7) 3 7
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
i', CITY l r r MA-DATE PER 6 Z3'O 7�Sr
JOBSITE ADDRESS f 0 cl Ck_ C7(r,�Y1a l•f C Pow OWNER'S NAME ' g P p n {4G.
OWNER ADDRESS TEL FAX
•
TYPE PRINT
OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL la"--
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: rk
PLANS SUBMITTED: YES❑ NO 0
APPLIANCES 1 FLOORS-4 BSM 1 2 3 1 5 6 7 8 9 10 11 12
BOILER 13 1 h
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER '
DRYER L__
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE - - I
INFRARED HEATER 1
LABORATORY COCKS
MAKEUP AIR UNIT •
OVEN r
POOL HEATER • R` E 1, E I V E
ROOM I SPACE HEATER — �r � 1
ROOF TOP UNIT i �T = i 1/
TEST -.. • ... ._
UNIT HEATER Dui �aRTnnrN
(INVENTED ROOM HEATER • by.-___ ---,
WATER HEATER f
OTHER
INSURANCE COVERAGE �
1
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES LI NO 0
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVE E BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE 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 ❑ 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 bes of my knowledge
`- and that ail plumbing work and installations performed under the permit issued for this application will be in com i ce with all Pertinent vision of the
Massachusetts State Plumbing Code and C apter 142 of j s V"I tale General Laws. ,�� �-, , ,/
PLUMBER-GASFITTER NAM S b. LICENSE# SIGNATURE''
MP❑ MGF❑ //��JP JGF� rGI 0 CORPORATION 0 4 PARTNERSHIP # LLC❑
COMPANY NAME te a S Pllivr.l)r^ `r f��h ADDRESS k �I S $ �1-( � E..S f' �
CITY D e n I11) STATE PIZIP 0 o-I, c- TEL r ,,
FAX CELL 7?L{ j S 5 [?I EMAIL V -t l((01,A s�G (j ( C f - ' _0-✓�'