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Home My WebLink AboutBLDP-23-11471 k! MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK .�y lir—= CITY y„, r,D MA DATE PERMIT#t�LIZ 23 `i/'-/ JOBSITE ADDRESS 0),, k o j C K OWNERS NAME f3 11,d,,,U G I POWNER ADDRESS TELg(61 713 4O7'j FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES 1 FLOOR-+ 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 _ _ 1 DEDICATED GREASE SYSTEM ' DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER C DRINKING FOUNTAIN J FOOD DISPOSER _ FLOOR/AREA DRAIN i INTERCEPTOR(INTERIOR) KITCHEN SINK j _ LAVATORY ROOF DRAIN ( C, 0 SHOWER STALL r �j :al ri SERVICE/MOP SINK • ( TOILET ItiL 9 4 2t23 rid/0 URINAL WASHING MACHINE CONNECTION ;,; r,iNG DEPAfZIf"'E' WATER HEATER ALL TYPES 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 POLICY tE. 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT ‘,.1 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 'th rtinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBERS NAME 6cp-dc..4) v P�l y LICENSE#;j.3i S1 i 't� SIGNATURE MP❑ JP/1 CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME ADDRESS 1/0 0 U)(ii 5 L/ Q t i�d CITY ,$awn 'fe- $ec -Ic STATE 1(4_,,t._ ZIP O ,'ih TEL 6-CZ gbit 43g1 el FAX CELL r EMAIL p,? "1-;t1 r i i5 @ C• ‘.1 r Co .,e... � ,-t MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I�1.-----1.F J'1�s c,�=?gin=,.-,� 4� CITY /anna.dil MA DATE PERMIT#, LD6 • 23 q.3 JOBSITE ADDRESS B)qC, JOCK OWNER'S NAME BJIII LJG,t,(15,--11 GOWNER ADDRESS TEL j 40 7 ),3 6,0 715- FAX TYPE OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL Pf-e SIT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 4 FLOORS-+ BSI 1 2 3 I 5 6 7 8 9 10 11 12 1 � BOILER BOOSTER CONVERSION BURNER ______1 COOK STOVE ' DIRECT VENT HEATER - DRYER i �--� FIREPLACE FRYDLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS —_i .____1 MAKEUP AIR UNIT OVEN POOL HEATER • ROOM SPACE HEATER ROOF TOP UNIT TEST4'4a UNIT HEATER . 2 UNVENTED ROOM HEATER • _j WATER HEATER - BJL OTHER --`?3 __--�. . t ___ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ,NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 13, 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. • -, CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT „1•, 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 wit all Pe ' en vision of the Massachusetts State Plumbing Code and Chapter'142 of the General Laws. Lti PLUMBER-GASFITTER NAME LICENSE#.3r1(43 S 'NATURE MP ❑ MGF❑ JP cSi JGF ❑ LPGI❑ CORPORATION❑#i PARTNERSHIP❑# LLC❑#i COMPANY NAME ADDRESS /LO g 1/'fi 4 e CITY lr--ei,l®f 6 eeLt STATE At Ot ZIP 0 dL 0-- TEL '"" FAX CELL 5-01 ,36 eLa,Ile EMAIL Pe4-err bit- 556 ih, c iI z