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HomeMy WebLinkAboutBLDP-23-11924 #A • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK =_>=1'i=�4 CITY ` Q�%vlUcl� MA DATE /•Z PERMIT# /�/ - 23 //9 1 JOBSITE ADDRESS /,?Ol g r OWNERS NAME J c f ect ct:c.I_ POWNER ADDRESS TEL';77`'-7-.5;X e- 7f4-'/ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:Eir. PLANS SUBMITTED: YES❑ NO❑ FIXTURES 7. 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/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 ��'.+ - SHOWER STALLROOF DRAIN Di © ° 2023 SERVICE I MOP SINK _, _ \-- 11- - ,�,�-6414 TOILET i URINAL s uiLulr\c„ v _1- Mt�ru. x �� '� WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER l:,odlace. l'"G'L Ofic4."� _ ill INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ErNO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El 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. `-` 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' compliance with ajTe"rient provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME tai!'T'e"-1 CcOl� LICENSE# , 3/7 z SIGNATURE MP El JP 0 CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME PC (-9(,r 776 J��; ,may, c tc>�- /?l�cj/ily� ADDRESS 7O k�P/���'!� /.�. CITY/ ram' c/�'� ) /lye `(c STATEA ' ZIP ( A(. .--/7-- TELSV`- 6/7C-- /'rro ' FAX Z CELL EMAIL C , Z7 I ;.�z.- =_ = MASSACE-IUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK W��.����` CITY ����,> �_ ": ��y Mr, DATE /".. ? , 2 PERMIT# Z,CY! "Zj • 73 JOBSITE ADDRESS Sip , /', G OWNER'S NAME Tasty gii.veg Lq,,��,/ OWNER ADDRESS `----- T ')PE OR TELLS /V.S 71�G / FAX TYPE OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL Cg,E,el�,•�. ❑ RESIDENTIAL❑ NEW:❑ RENOVATION: ❑ REPLACEMENT: ar PLANS SUBMITTED: YES❑ NO❑ APPLIANCES-4 FLOORS-4 951%4 1 BOILER 5 6 9 10 BOOSTER MU MN I 1 i CONVERSION BURNER —.1 COOK STOVE DIRECT VENT HEATER - DRYER, FIREPLACE Mill�— FRYDLATOR — - FURNACE MIN GENERATOR �-- - GRILLE ---- — INFRARED HEATER LABORATORY COCKS 1.11.0.1 MAKEUP AIR UNIT OVEN i - -M - POOL HEATER ra ROOM;SPACE HEATER N�uma�,'f; /�� ROOF TOP UNIT V f - TEST UNIT HEATER IIIMMIIII.Irar47' IINE Ui�DI AF3T UNVENTED ROOM HEATER EMBI,M=WATER HEATER t riBni In VIM ______ r 0 It INSURANCE COVERAGE - - I have a current tiabih insurance policy or its substantial equivalent which meets the requirements of MGL.Ch,142 YES, 2'wo I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ❑ LIABILITY INSURANCE POLICY El 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 waive;;this requirement. .y ''.. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT ❑ I hereby certify that all of the details and information I have submitted or entered regarding this application are true and and that all plumbing work and installations performed under the permit issued for this application will be in in lian • Massachusetts State Plumbing Code and Chapter'142 of the accurate to the best of my knowledge L`� general Laws. ce with all Pertinent provision of the PLUA�BER GASFITTER NAME ��,ti, LICENSE# 2.3/7 MP ❑ MGF❑ JP 0 JGF❑ ❑ CORPORATION SIGNATURE ❑# PARTNERSHIP[]# COMPANY NAME C. C200- - � a,� LLC 0 �?ZC7��/���i' ADDRESS 70 z:', CITY o�_ C' zz2j,_ ' ��� STATE lid_ ZIP r FAX TELS CELLr� rn�'/'-L EMAIL���Q N-77- ) 6