HomeMy WebLinkAboutBLDP-20-003785 7.----_' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
.•. t CITY/TOWN S nU i ll Y.41/ I4 f7/ MA DATE 1/34 0 I 0 PERMIT# P Q' I
JOBSITE ADDRESS / I DyU,i/L 57a,Ue OWNER'S NAME I d 11 ii eit
P OWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 111/
PRINT
CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: L`� PLANS SUBMITTED: YES❑ NO
7 8 I 9 10 11 12 13 '
2 3 4 5 6
FIXTURES 1 FLOOR—, UM 1 (BATHTUBI
I
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM —
DEDICATED GAS/OILISAND SYSTEM
DEDICATED GREASE SYSTEM r
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER • L
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN `
INTERCEPTOR(INTERIOR)
KITCHEN SINK _ I t
LAVATORY
ROOF DRAIN
1 —'--
SHOWER STALL
SERVICE/MOP SINK i
TOILET 33
URINAL N
WASHING MACHINE CONNECTION I_ l
WATER HEATER ALL TYPES 7 C3ZJ --
WATER PIPING
_OTHER 1
.'— INSURANCE COVERAGE: —/
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES f NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND
OWNER'S INSURANCE WAIVER:I am aware that the licensee dopy not hive 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 [21
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 a rate to the best of my knowledgf
and that all plumbing work and installations performed under the permit issued for this application will be in co ' cad+' all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME 191114/if ill 4&r-er LICENSE#if/7 7 SIGNATURE
MP JP❑ CORPORATION et PARTNERSHIP 0# LLC 0#
COMPANY NAME C4°L ic Cli P i'it' /!VC ADDRESS ? 0 f 8ox LiZ
CITY 5Oti7'H De.4/4i is * STATE/ IA ZIP U L e t t TEL Sv6`- , ` 22,Z sP
FAX CELL EMAIL C.4t.PQ.c=O cif p/um 6 Js71 0 yahoo . L,s&' ,„
al-1-
'"" MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY c u- (J-1 1/14 f7m n)TI-4 MA DATE 1 13120 d 6 PERMIT# Z/V a'd0-X J78f
JOBSITEADDRESS 15 Q -7-0 Rc' OWNER'S NAME Ed l ¢lneri
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL[V 1‘Pb.o�
PRINT
CLEARLY NEW: ❑ RENOVATION:❑ w REPLACEMENT: [11.7 PLANS SUBMITTED: YES CI NO
APPLIANCES 1. FLOORS-* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER t
•
BOOSTER
CONVERSION BURNER _
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GENERATOR
GRILLE ! ,
INFRARED HEATER -
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER '
ROOF TOP UNIT �Q
TEST
UNIT HEATER
UNVENTED ROOM HEATER ffi �.
WATER HEATER ' ., �, 7.1
I
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 24
❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERA E BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 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.
CHECK ONEONLY: 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 best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compl wit 'Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME 3 rr.4,) Hi bb rcl LICENSE# /1177 SIGNATURE
MP IMGF❑ JP❑ , JGF[] LPG'E3 CORPORATION PARTNERSHIP 0# LLC #
COMPANY NAME Cie (d f41+s141 ; iLRieerw . 'a' ADDRESS pc• ec Litc
CITY Yew-7( 0(.4.6 , r STATE ern. ZIP 0 Z. 6 j 0 TEL 5-b -J `-ZZ z.F
FAX CELL EMAIL