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Home My WebLink AboutBLDP-23-11753 _ I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 1-,�: Cm' 5- \�O 1r bi MA. DATE J O/3/ #& � � JOBSITE ADDRESS 9 9 5.4 d/e v 2d- f� OWNER'S NAME a`h e� / U i` p OWNER ADDRESS S.v vl-,-t TEL 77y -.27d -/07,5-FAX TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL PRINT ❑ RESIDENTIAL Dg CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:21 PLANS SUBMITTED: YES 0 NO 2 FIXTURES FLOOR* I SSMT I 1 2 3 I 1 7 I 8 I BATHTUB I 1 5 5 9 I 10 I 11 1 12 13 I 14 CROSS CONNECTION DEVICE I I SYS I 1 I DEDICATED SPECIAL WASTEI I I I I 1 I I I I I DEDICATED GAS/OIL/SAND SYS I I I I I I I I DEDICATED ED GREASE SYS I I I DEDICATD GRAY WATER SYS DEDICATED WATER RECYCLE SYS I 1 DRINKING FOUNTAIN DISHWASHER 1 FOOD DISPOSER FLOOR IAREADRAIN Il I I I INTERCEPTOR(INTERIOR) 1 I I I I I KITCHEN SINK I 1 I LAVATORY .- I I I I ROOF DRAIN- ISHOWER STALL FtE IF E IL V F D SERVICE/MOP SINK TOILET l I I URINAL +JCS 1 0 3 ZQ1I I WASHING MACHINE CONNECTION WATER HEATER ALL TYPES I �v l C1 t l 1 l -- ni`--)-DART6 FUT WATER PIPING ( I -- ----� -- - - f OTHER I (� 1 I1111 1 1 I 1 I 1 1 1 1 INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent wh ch 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 OTHER TYPE OF INDEMNITY 0 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 BOX ONLY: OWNER ❑ AGENT ❑ Signature of Owner or Owner's 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 with all Pertinent provision of the Massachusetts State Plumbing Code and Cha ter 14 ,of the General Laws. PLUMBER NAME 1111,1 '<61 V1-e SIGNATURE ' LIC# a a 75-5- MP 0 JP 51 CORPORATION ❑# PARTNERSHIP ❑# LLC 0# COMPANY NAME 7o(lc ',Carve 16 ii IrGGtil' ►A y ADDRESS: 3 c1 ✓ri a n° to(Ai reci • CITY S-V orret STATE Ili Co ZIP 0.-a 6 b V EMAIL ` y, t✓ 4 e t 0 ' CO Virl TEL CELL TO - 6 515' S<c�‘, FAX MASSACE-IUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK h, _ '. kr iti CITY J- /la a:jArl I\4,4 DATE PO/ J/�3 PERMIT JOBSITE ADDRESS / 9 ,5-iv A'Y I'al OWNER'S NAME ✓om�� f4a�"21 GOWNER ADDRESS S c'.r m t TEL '774-a7O '/-d 75— FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ( RESIDENTIAL PT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: (a, PLANS SUBMITTED: YES❑ NO( i APPLIANCES 1 FLOORS-4 BSM 1 2 3 4 5 6 7 ° 9 19 111 12 '13 14 BOILER BOOSTER CONVERSION BURNER, _ COOK STOVE DIRECT VENT HEATER DRYER _ FIREPLACE FRYOLATOR FURNACE GENERATOR _ (-- GRILLE INFRARED HEATED. _ LABORATORY COCKS UP AIR UNIT I" OVEN .e E I V E70 POOL HEATER ROOM/SPACE HEATER F T 4 ROOF TOP UNIT TEST _ 1- - --- (3 J I L @i r tG f1E PA r<I FTE N T UNIT HEATER I uY: UNVENTED ROOM HEATER WATER HEATER __ OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [Y1 NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [g 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 i, 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 compile ce wi ail Pertinent provision of the `"• Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME 70 h l'` 1(:6 l'" LICENSE## Q .:75'3— SIGNATURE MP❑ MGF❑ JP I . JGF❑ LPG' ❑ CORPORATION❑# PARTNERSHIPTn/ ❑# us;❑#COMPANY NAME CIO( K6iPL ! ' 0c [ J Ih9 ADDRESS 3ci 01Po i)ia'1 P°A. CITY '5' I a r Ns STATE m ci ZIP D a-6 Co 0 TEL FAX CELL 50$ - 6 b's"-0-6 S6 EMAIL J l<GI/lt .e. 4 s-_e s/G In 6 c; . Ca. `41 CbLL