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HomeMy WebLinkAboutBLDG&P-23-9615 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _�— CITY �if���'t !/ 'i "T/� MA DATE A/ f, 2 3 PERMIT#B4-b Z 3.f � - JOBSITE ADDRESS 2-F< Ail//it/3c.<:e)(fsJ OWNER'S NAME AG'yiVi if/fa/ 1 OWNER ADDRESS TEL SO ''22t"/27S- FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Le PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:2/ PLANS SUBMITTED: YES❑ NO❑ 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 y 1/ r_ INTERCEPTOR(INTERIOR) j/ KITCHEN SINK 'Or' ' ��7�1 LAVATORY • e O 1 `�`i ROOF DRAIN `j, 1-1::..1; SHOWER STALL iiLDid - "r_ ZTM ►LT SERVICE/MOP SINK . -- TOILET _ URINAL � WASHING MACHINE CONNECTION ; WATER HEATER ALL TYPES / • Ctil Wi WATER PIPING _ Zi OTHER 0.1 lI .-i INSURANCE COVERAGE: �/ I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES(J� NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY V 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 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 th all Pe inent prov' ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. � ��j PLUMBER'S NAME Xi e �oiteP5 LICENSE# .3/SY'/ . .ram 7- `'SIGNATURE MP ❑ JP El" CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPANY NAME w/efl5' r ?` -/ ADDRESS 2c 6"A/i7N'6-l�fr/ CITY (tom);" r.9%.?,t4r��f•/ STATE 4/tt ZIP G2 73 TEL 77 f-8'36, .Za 3 FAX CELL EMAIL :1YK/e5'1-N Pi-" l3ci'-'42 ,f/j.&'C'f'f I MASSACHUSETTS ET TS UNIFORM A Pf�LIC�4TION FOR4 PERMIT TO PERFORM GASFITTING WORK " "- -( MA DATE NAY. / Z�''�3 PERMIT* i fll.n�- L3 JOESITEADDRESS u/twt6-47:VA,i 'A GOWNER'S NAME____MG A// ____ OWNER ADDRESS TEL J v `2.2-/-/Z75 FAX TYPE OR PRINTOCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL CLEARLY ❑ RESIDENTIAL[ NEW:❑ RENOVATION: ❑ REPLACEMENT: 27 PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS-* 6SIVI BOILER 5 6 9 BOOSTER ®® 13 CONVERSION BURNER © ______I COOK STOVEIIIII DIRECT VENT HEATER DRYER FIREPLACE —�— FURCiLATOR mim FURNACE - GENERATOR --r GRILLE ---r-- - INFRARED HEATER —�---- 1. - LABORATORY COCKS � �I OVENPAIR UNIT WailaJI OVEN POOL HEATER IIIIW jir& �� - . F ROOM/SPACE HEATERMIM _a� # 1 `3 ROOF TOP UNIT —__ 1 TESTgm UNIT HEATER Mini ® +Att � . INVENTED ROOM HEATER -��= WATER OTHER HEATER / ---� OTHER 1 VIM .. INSURANCE COVERAGE ---� I have a current Iiabifl insaarance policy or its substantial equivalent e tti I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE sAPPROPRrequiIATE nCI�(pELOWOW 11; 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 my signature on this permit application waives this re requirement.y rEoiyEnt. .`r `� SIGNATURE OF OWI ER OP,AGENT CHECK ONE ONLY: OWNER ❑ AGENT ❑ I hereby certify that all of the details and information I have submitted or entered regarding this application are true - and that all plumbingwork p `; a and installations performed of the Genpermiteralrovision PlumbingCodeandaknowledge Laws. "the PLUMBER-GASFITTER NAME G,t/lay,,./6 6,acide T LICEI'dSE# 3/,s-ey I ATURE MP❑ MGF❑ JP [✓re JGF❑ LPGI ❑ CORPORATION ❑¢f PARTNERSHIP❑/� n��P LLC❑ : COMPANY NAME CITY $i �/a„i7/ 17( ADDRESS �,✓7-7Av ` .e "� STATE_ !U/ ZIP G26� FAX TEL 77 : -2�7� CELL EMAIL