HomeMy WebLinkAboutBLDP-23-11729 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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__ F=e CITY Ct y /I,h t r L f\_ MA DATE PERMIT#( Di'-L 3 i 1 I zq,
JOBSITE ADDRESS_____ ,ait:Fc, OWNER'S NAME ,,-4I -5I1 k i 3 a
POWNER ADDRESS j„..m 5 /j l ,� n ` h<. TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO b
FIXTURES 1 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/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE I MOP SINK
TOILET 4 C D
URINAL -� K E C .1.- -_ ..._. _
. WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES f �.
WATER PIPING
OTHER arRpf fMEN —,
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES - I NO 0
IF YOU CHECKED YES, PLEASE INDICATE THE TYP 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 ONLY: OWNER ❑ AGENT ❑
SIGNATURE OF OWNER OR AGENT
LU 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 Chapter 142 of the General Laws.
PLUMBER'S NAME LICENSE# tic)(--t 1.) ..- SIGNATURE
MP❑ JP, CORPORATION❑# PARTNERSHIP❑# LLC❑#
/Vet—
COMPANY NAME I .) . \ kc-C.L.;I .e S ffi
ADDRESS / L/4, CcDt-A,A7/0ti0 Si
CITY ' N---( Kiel'' STATE ' ZIP (-16 1 TEL
FAX CELL <O U J v �C�/ c�EMAIL ��U I /(,) A [�L 5 f �c L
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WO
RK
'6 .f` CIT( - k4A DATE
"�= PERMIT# gc.06..23-- `r)6
JOBSITE ADDRESS ,/c.-'` f4 1, .(-r. C<e , OWNER'S NAME
G
OWNER ADDRESS TEL TEL
TYPE OR FAX
PRINT PE OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL
❑ RESIDENTIAL
CLEARLY
NEW:❑ RENOVATION: ❑ REPLACEMENT: 7f..%---- PLr1IJS SUBMITTED: YES ❑ NO
g„,
APPLIANCES 1 FLOORS-- SS11A 1
BOILER 4 5 6 7 ° 9 10 I'I 12 13 1�
BOOSTER
CONVERSION BURNER
COOK STOVE J -----
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE '—�—
INFRARED HEATER
LABORATORY COCKS —_
MAKEUP AIR UNIT •
OVEN
POOL HEATER
•
ROOM/SPACE HEATER --
ROOF TOP UNIT ---
TEST
.__ . . _ . . . . ._
ec: LI _ D
UNIT HEATER
UNVEh1TED ROOM HEATER
WATER HEATER P ��
OTHER
By: --- L
INSURANCE
I have a current lial�il-i insurance policy or its substantial equivalent which DVmee MU.s the requirements of M .Ch.1 42 YES�p .
❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG_. Y CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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 ray signature on this permit application valves this requirement.
SIGNATURE OF OWNER OR,AGENT CHECK ONE ONLY: OWNER ❑ 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 compliance with all Pertinent provision of the
' Massachusetts State Plumbing Code and Chapter-142 of the General Laws.
`i
PLUMBER-GASFITTER NAME '^'
LICENSE#1,,, SIGNATURE
MP ❑ MGF❑ JP 54_JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC 31:
COMPANY NAME c� � �IJd l rt'I— ^S t/(;)- 0` /(
ADDRESS / 1/1 (--'cl-P/17;
CITY
`('\.u.CA STATE - ZIP Z O'
TEL
FAX CELL /Q EMAIL