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Home My WebLink AboutBLDP&G-23-11793 • MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM PLUMBING WORK �F CITY >_ MA DATE .' ' 2- PERMIT# 'Z�j-//��3 JOBSITE ADDRESS /1//4 Gj f4S (JAL'4.Ii OWNERS NAME OWNER ADDRESS •,-c-IX TEL Z� TYPE OR OCCUPANCY TYPE COMMERCIAL �� FAX PRINT ❑ EDUCATIONAL ❑ RESIDENTIAL /, CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: g PLANS SUBMITTED: YES❑ NO 2 FIXTURES I 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 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN !ID• - DISHWASHERAI INTERCEPTOR(INTERIOR) ', !, KITCHEN SINK E�iM111111 LAVATORY ) � ROOF DRAIN B I L Di ��1�1 SHOWER STALLEr_MI Mull . SERVICE/MOP SINK atmMI TOILET URINAL _== j WASHING MACHINE CONNECTION =-- WATER HEATER ALL TYPES OTHER _�_ INSURANCE COVERAGE:I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Q NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY g OTHER TYPE OF INDEMNITY 0 BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required b Chapter 14 Massachusetts General Laws,and that my signature on this permit application waives this requirement. y p 2 of the T E SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER �t I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurateAGENw 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 Chapter 142 of the G neral Laws. to the best of my knowledge PLUMBER'S NAME Mi C keL -C13it ' LICENSE#06V. `" SIGNATURE MP❑ JP Q CORPORATION ❑# p fb. � PARTNERSHIP❑.# LC❑# COMPANY NAME I/ ��CJ: r f a / ti ADDRESS (,- CITY aN/ / STATE -'A_ ZIP L (a4 i'' TEL L i /a, FqX CELL EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING TIIVts WORK 4.•% : ► !/ 1�4A DATE !�J Z JGESITE,4DDRESS 1� PEI EMIT - OWNER'S NAME d G OWNER ADDRESS , T 'P C>F� T / - r Z/ FAX PRINT OCCUPANCY TYPE COMMERCIAL CLEARLY ❑ EDUCATIONAL ❑ RESIDENTIAL [ NEW;❑ RENOVATION: IDREPLACEr REPLACEMENT: Q PLANS SUBMITTED: YES❑ NO El APPLIANCES -1 FLOORS--F ssM - BO ST =®- BOOSTERER =®=® 13 14 CONVERSION BURNER v Ellv COOK STOVE InDIP,ECT VENT HEATEREll IIII. DRYER arkarmilMINILIMIIIIIII -FIREPL ACCin, n,FP,I'CiLATOR --GE ri, mon - GRILLEElliATOR = — -- - MI IIVFI;AREC)HEATER I -- MAKEUP AIR UNITEll 11111 Ell Mill LABORATORY COCKS IIII "!, POOL HE11.01.11111.11-1111 el EN.I..maiwiliaiLliimm ATER ............ ...1 ROOF TOP U -...., a, Nl i IIIIIIIIMMIIIIMMINNI UNIT HE,4TER ®-- MINI -5-im -,,„.., .. , �� [INVENTED ROOM HEATERum WATER HEATER — i11 o i"I-IEI, ---_--=ill a--- — --__ 1111.11 i GE I have a curre INS -� 1111111111 all Ilt liabfli insurance policy or its substantial equivalent which meets the requirements I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX S �IGL.Ch.142 YES [l NO ❑ LIABILITY INSURANCE POLICYBELOW • DVVr�ER',INSURANCE WAIVER: I am aware that the licensee does noI OTHER TYPE INDEMNITY ❑ BOND ❑ Massarhus.etts General Laws,and that mysignature on this permit application waives this requirement yaWe tfre insurance coverage required by Chapter 142 of the ' .� SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER =:` I hereby certify that all of the details and information I have submitted or entered regardingthisAGENT ❑ L and that all certify that plumbing and installations performed under the permit issued for this application will be in with all Pertinent and Massachusetts aset State workPlumbingCodeapplication complianceo true and accurate to the best ` � and hapter 142 of the of my knowledge Li j PLUi�46ER r,ASFIT'f ER NAME i' ", 'znP�al Laws. } provision of the L tfjr: i 1, . MP❑ MGF❑ JP JGF LICENSE# �--� t '❑` ❑ LPGI SIGNATURE COMPANY NAME N ❑ CORPORATION❑ t r0 ' PARTNERSHIP❑�r LLC 0�y; ADDRESS - C ,OL CITY 1%; STATE �� '7 �` FAX ZIP—AL-C,L TEL EMAIL �"—