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Home My WebLink AboutBLDP&G-23-11624 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK e-- CITY (Al ,k7 Q v'tM v U• MA DATE 3 PERMIT# yl:1-149—P13 -7/ JOBSITE ADDRESS (-1 ChonJ1-ck) c 1" ci OWNER'S NAME a iy( C 6 id S- POWNER ADDRESS S G br< TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL 2 PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO[� FIXTURES T FLOOR- 9SM1 1 2 3 4 5 6 7 B 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 I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ¢ ROOF DRAIN /1 SHOWER STALL41v* a4�� A • SERVICE!MOP SINK t3 0 9'2023 TOILET �� URINAL BULDING DEPARTMENT WASHING MACHINE CONNECTION By' — T-- 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 t' NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E 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 1Q,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 corn.liance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / . PLUMBER'S NAME —ye in.-y‘ 16 u t LICENSE# p.:a7 5. SIGNATURE MP❑ JP® CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME T Q C k is y vt?. 4 v. ill a G 4(t4 9 ADDRESS 3 Imo vh k CITY J -\/G If m STATE ill t' ZIP 0) b b TEL FAX CELL . 5 ' SL EMAIL J 1<a+'1 '10 kQ b • (0 Pvt. =� I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK (7=74-- CITY: ry MA. DATE: ` `i V 'i PERMITI JOBS(I>_ADDRESS: L v C h o n cl u,/ C tt- OWNER'S NAME: a) v y e C ti‘ I ct s GOWNER ADDRESS: S-'c i h'1 t TEl FAX; TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL PRMIT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED: YES❑ NOZ I APPLIANCES? FLOOR-} I Bsmt 1 I ? 3 1 4 5 6 7 I 8 9 10 11 12 13 I 14 I BOILER BOOSTER I I I I CONVERSION BURNER I I 1 COOK STOVE I j I DIRECT VENT HEATER I i DRYER I + I FIREPLACE I I I I 1 IFRYOLATOR FURNACE I I I J I GENERATOR I j I GRILLE I j I INFRARED HEAL I LABORATORY COCK I I MAKEUP AIR UNIT OVEN I POOL HEATER R E C ICE V E D ROOM/SPACE HEA I ROOF TOP UNIT I , I • _ et 4 U I TEST i 1 I i UNVEN ED ROOM HEATER I I i ;5 I FUUILDI NG D E1PARTMENV I WA+Lx HELL' I i 1 I I 1 1 T` 1 - I I 1 I 1 1 1 I 1 1 i I I J 1 I I 1 1 J INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirement of MGL Ch.142 YES NO 0 If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY Q 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 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 all Pertinent provision of the Massatthusetis State Plumbing Code and Chapter 142 of the General Laws. y7.4' PLUMBERIGASFII T ERNAME ,) G�� I(G +-< LICENSE# r 7 SIGNATURE COMPANY NAME: TO(lc iC cz n e K a 4� 'v �, c S ADDRESS: 3 `i lM U t' 144 c CITY: 5 kit/ E+'v‘ STATE: VY\ ZIP: (] (c L( FAX TEL: CELL: �O?�h 5 -sb c EMAIL: j Is �+c s- Y u ii,o MASTER❑ JOURNEYMAN LP INSTALLER l=i CORPORATION 0 t: PARTNERSHIP CJ' I L C