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HomeMy WebLinkAboutBLDP-23-8507 Mc Ap Do C e_ 1 I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK t '__ 11,, .�_� CITY y�Ym �Mt) MA DATE 519 , 23 PERMIT#itLOP-23`9S-D7 JOBSITE ADDRESS -7 f YDVc S+r-ee 1' OWNER'S NA/(/MEpcn(1re A �MJC.Iv , OWNER ADDRESS ?- U ?( (W 9 I nton r m TEL5U LPN "U5 AX x TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ONAAL ❑ ' RESIDENTIAL,' PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENT:►.1 PLANS SUBMITTED: YES❑ NO4 FIXTURES 7 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 DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM • DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER • FLOOR 1 AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN • I SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALLTYPES X1 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 ❑ j IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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 in complia ith all Perti provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME C.- r l S. LICENSE# ,?y� SI ATURE MPZ, JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME C G r i F. R; e cl e l l t Son ADDRESS '7 75- t c ee. CTY Os t e r v � 1 l e STATE f •M A ZIP 0 'D co 5 S TEL 5 o s- H - C9 3Co 5 FAX JOO 'LIZ�- bt%O CELLS5DcIS"4ZQ"it-5y EMAIL *enn ( ecif2AI - C©m L MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK _ PERMIT#R(.)P-23-9 9`7 CITYL ....:. MA DATt ._O � z JOBSITE ADDRESS;, _ V siYee -_ _ DOWNER'S NAME endic a1 -1Y-A./P LLt(\Q. 3 G TEL O. FAX OWNER ADDRESS Q , .> a .yj !n 4.... 5 ? 4614'gcb c---,..__. TYPE OR - 01 7- PRINT OCCUPANCY TYPE COMMERCIAL;.__..; EDUCATIONAL! ? RESIDENTIAL% CLEARLY NEW: RENOVATION:Li REPLACEMENT: PLANS SUBMITTED: YES V NOcIi APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 I 6 7 8 9 10 11 12 13 14 BOILER f ;III I BOOSTER I I CONVERSION BURNER E �� COOK STOVE II__. DIRECT VENT HEATER l_ - DRYER 1-- FIREPLACE i 1 FRYOLATOR FURNACE I_„ II II . ., I IL, .. GENERATOR i .. - ,..•.__.' ...._, ,i GRILLE I ; i , INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT ,__.�.?,._. � __. .._ � OVEN E ,: POOL HEATER - - C . _. ROOM/SPACE HEATER t ! ROOF TOP UNIT i ' I I - - I 0 'f. � j , TEST ,, I --�- --'' - � _d mQy,16. _ � UNIT HEATER V. i L ' ` UNVENTED ROOM HEATER _ 1 _ 1— — - - a1lt.L►tNc� WATER HEATER ,_._._._ av- OTHER . - - 1 -- .- . L e t - I ¢ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES t`\NO , 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY I,,... OTHER TYPE INDEMNITY ;; i BOND ,s 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 L,. 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 compile ith all Pe ' t provi • he Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /�J PLUMBER-GASFITTER NAME ( c r I S Pi I I 1 I LICENSE#LLB' , S ATURE ' MP MGF JP, JGFI,,,_ LPGI' , CORPORATION t PARTNERSHIP #;a LLC 4 COMPANY NAME:; ,( 1 l n ! e .e d ,i I r_ , r, I ADDRESS 7 7 ',---5 iN-1 c, I n 5 c r e CITY ; r✓%-5tet �� , 1IL Si ATE;;',./ , ZIP; C• 3,c' TEL'; ` c ti �c FAX - RO �I ftELL l L :. cAIL(. 'n@,cooly..t ei1 (.4m-_.a _._i