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HomeMy WebLinkAboutBLDP&G-23-11655 • MASSACHUSETTS UNIFORM APPLICATION FOR A P RMIT TO PERFORM PLUMBING WORK =1 CITY �,a�� �� L MA DATE ¢ 2 2 3 PERMIT# ilf� Z3~l/4-S- JOBSITE ADDRESS ( j'7 1(1; . OWNER'S NAME ;1 l�_5 P OWNER ADDRESS 2 t / / 11 ,( llt/Z,�ji,i r ��r itt,r b, 4 EL (• 7-959,4 .e FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT Er- CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:( ` PLANS SUBMITTED: YES❑ NO❑ FIXTURES 1 FLOOR-4 J BSM 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 •ROOF DRAIN ___I SHOWER STALL SERVICE/MOP SINK TOILET , —_______I URINAL _ _ _ _ WASHING MACHINE CONNECTION �; -F_ 1 WATER HEATER ALL TYPES - WATER PIPING OTHER -d 4- 423 - ..- s • DE ART41CNT i y— 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 TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i OTHER TYPE OF 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. T 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 cc rate to the be y( knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co lianc w all Perti n r ' n of the Massachusetts State Plumbing Code and Cha ter 142 of the General Laws. / PLUMBER'S NAME Tr.-?r+ ,47 14 /c-n ^, LICENSE#/ ry SIGNAT RE MP V JP❑ CORPORATION❑# PARTNERSHIP LLC❑# COMPANY AME J��5/1 A 71,91/a444, PLC-"�-eit ADDRESS :).(7 /`0/044 (/1j,c, t��, C CITY r /V ({ /1�� 7 jilt- STATE All/ ZIP Ci °L CI`/ TEL ,Se 3 _ �,S -20 S7 FAX CELL EMAIL SO"I✓C"/%}6f-' %1 6) Co/7c,i' - Ar/l =� P B>hASSAd"E6�tSETTS UNIFORM APPLICATION FOR,qPE'i) (s ''MIT O PERFORM GAS FITTING I+ ORK �: L r CITY ' " ��� d:e ai v MA DATE Z 3 JOBSIT ADDRESS ? �j� PERMIT f; OWNER'S NAME ` aJ OWNER ADDRESS 2- �� �' .�l �4 G TYPE OR ... :Lk,/ y 4I EL 6i �] . gS9Z , PRINT OCCUPANCY TYPE COMMERCIAL❑ CLEARLY EDUCATIONAL ❑ RESIDENTIALka"-' NEW:D RENOVATION: ❑ REPLACEMENT: IV APPLIANCES FLOORS-� PLANS SUBMITTED: YES❑ NO❑ BOILERillaillgt14111111,111111 BOOSTER •I31,,COhJVERSION BURNER,COOK STOVE la DIRECT VENT HEATER - FIRYER1111riallignalliarill MIN _- FIREPLACE F-RYOLATOR _G -v__ - GRILLE -_-_ - INFRARED HEATERLABORriallniallrilliallifin________ --_ MAKEUPJ AIR`UNOCl;SMN IIIIII _all all POOL HEATER IT =—_____= _ _ _ v�v6__� ROOF TOP UNIT II riminnahmm _UIJIT HEATER ®I INVENTED ROOM HEATER _®__v ,"'" �' WATER HEATER _ ,1 •I I; OTHEf, � ± �_� all MINI _ _� MI 111111 v- _ v-v��� i �f GE I have a current liab'' INSURANCE -�- ala insurance policy or its substantial equivalent which Dvmee s the requirements of M__ _— I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATEMGL. Ch.142 YES U © BOX BELOW ❑ LIABILITY INSURANCE POLICY R"-- l�VdtJER',INSURANCE�r OTHER TYPE INDEMNITY ❑ RIVER: I am aware that the licensee does not the insurance coverage required by BOND Chapter❑14� Massachusetts General Laws,and that my signature on this permit application waives this i ,ie u of the `.f requirement. .s SIGNATURE OF OWNER OR AGENTCHECK ONE ONLY: OWNER n f I hereby certify that all of the details and information have submitted or entered regarding ❑ AGENT ❑ and that all certify plumbingthat workp • installations performed under the permit issued for this application will be in com liance Massachusetts State work andPlumbingCodeg 9 this application are true and accurate .the and Cha ter•I oft est my know dge �^ general Laws.Li j P all r rtin� t pr. vision of t PLUMBER-GASFITIER NAME ;5/1 l9 GIN LICENSE, / - Iu1P I a MGF❑ JP CENSE#�7.dY/ i ❑ JGF❑ LPGI CORP P\TION❑#f A'I AT LL COMPANY' NAME c7 /t PARTNERSHIP❑## a 4 LLC❑#�: CITY �"�k\DDRESS -2 --eye,y 19 A. FAXSTATE MA ZIP 0 .2- 6 O J S CELL TEL �j�- EMAIL S 4/ •LL,c 5 - L