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Home My WebLink AboutBLDP-23-11709 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ,--__:-.----4‘_--------_. CITY MA DATE PERMIT# ,PLUM- z 3-W 7 4". (' (/ ;t JOBS(TE ADDRESS fI f C f-� <Jcc , OWNER'S NAME 3/I W1 ,..; J POWNER ADDRESS TEL .2FiI 7i 6(3'7`6- FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL gf PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ FIXTURES- FLOOR-4 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/OILISAND SYSTEM DEDICATED GREASE SYSTEM " DEDICATED GRAY WATER SYSTEM - DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION t WATER HEATER ALL TYPES R _]' # d �� WATER PIP NG _ OTHER lib i l -- I/ e' c nQ'�, - BIJILUiNG DE'ARTMCNT i - INSURANCE COVERAGEJ- B 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 0 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 t Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT L:LI 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 Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Q/� f 500.1 PLUMBER'S NAME (41.401Q )J f(6,5 LICENSE# \Y 0(.1 , SIGNATURE MP❑ JP 0 II CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME I t I gp-f M S hoe r j' ADDRESS !CQV (fi t 111 'L-?i ea' CITY 2lrGl/tt 0 4 STATE /4 ZIP b 2..4.5 TEL 6-tor 34 411Qg 14 FAX EMAIL (et t`I�LJPsi'15' .rq.1 l r Co CELL @ G �. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK '',-4 7,5J N(-fit O U"&�`. L• CIT`( MA DATE PERMIT a �+ B�t)4:- z 3 - 9y .� JOBSITE ADDRESS (C� 2C k Doc./‹ OWNERS NAME 64 ii !}- OWNER ADDRESS TEL 4$/ 7 3 6o? FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 'E 'PRINT ❑ F�SIUENTIAL CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: f ❑ PLANS SUBM ITTED: YES❑ NO❑ APPLIANCES FLOORS-+ 6SN 1 2 3 4 5 6 7 8 9 10 'i'l 12 •I—�,, BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER —_ FIREPLACE FRYOLATOR FURNACE GENERATOR • GRILLE INFRARED HEATER ---- LABORATORY COCKS —� MAKEUP AIR UNIT OVEN POOL HEATER • ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER R E C E I-V E D UNVENTED ROOM HEATER WATER HEATER —~ OTHER SEP 14 2023 BUU DING DEPARTMENT By: 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 ❑ 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 nay 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 best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance wit rtinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.Li PLUMBER-GASFITTER NAME Ga i G ply( S 5 LICENSE# .J -3� SIGNATURE MP ❑ MGF❑ JP ❑ JGF❑ LPG' ❑ CORPORATION 0 41 PARTNERSHIP❑�� LLC❑#! COMPANY NAME e I15.0'it, V its ADDRESS IC 0 W 111 SS .t) tQ" CITY '34 ®t-.p g,oq a-k STATE 4L a ZIP e TEL a TEL FAX CELLI' t` :l Lj ( —1 4' EMAIL e,k_i°Y` (,'ryTri lr�