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Home My WebLink AboutBLDP-24-116 MASSACHUSETTS UNIFORM APPLICATION FOR A E IT TO PERFORM PLUMBING WORK _ f=s� CITY Y�( /LY��v.V/�1 ATE .� PERMIIITT#DcO('--14— 114- _ LLL r 1 - /Fd N t/V U,t � Y 'SNAME i JOBSITE ADDRESS `�' V r l'/V � r POWNER ADDRESS i` TEL AX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL❑ RESIDENTIAL❑ PRINT CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:0 PLANS SUBMITTED:YES❑ NO 0 FIXTURES 1 FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE 4D i/ - DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM ' DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM _ _ - DEDICATED WATER RECYCLE SYSTEM i DISHWASHER DRINKING FOUNTAIN - FOOD DISPOSER ' FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) A�— KITCHEN SINK 601 t � _ ... LAVATORY ROOF DRAIN SHOWER STALL SERVICE 1 MOP SINK TOILET URINAL j WASHING MACHINE CONNECTION — WATER HEATER ALL TYPES WATER PIPING1./.-----. OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ' NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE F COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABIUTY INSURANCE POLII OTHER TYPE OF INDEMNITY 0 BOND 0 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 1 Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 0 SIGNATURE OF OWNER OR AGENT LU I hereby certify that all of the details and information I have submitted or entered regarding this application am true a 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 compli ce with all Pertinent provision of the Massachusetts State Plu inngg,C,otde and apter 142 of the General Laws. C PLUMBER'S NAME i LICENSE# /�� SIGNATURE M JP IG-� 7 YCORPORATITI/O'N/❑�# PAADDRESS ❑.#„)-0/ /Q LLyC�❑# COMPANY AME tJ',l�,G,R,, l P`k i l RE 2 2/ 7V-6 1 Ci�V y /2p� CITY i Vt ` STATE ZIP I • TEL�. bO l� FAX CELL EMAI /ILO I 04 6)5 / I ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES 1 ' A'� f)ASSACHUSETTS UNIFORM APPLICATION FOR A PERMET TO PERFORM GAS FITTING WORK e, lk, ,J' '` ! if V �/ l- / �;��,L-�--,s` CITY �""t '4� ;: MA DATE Z 2 PERMIT# QiraG Z`t - 93 JOBSITE ADDRESS LI Tit)1 iV/V O& �,&iJ� f 'C`� 10°ME G __h_frc:/x____________ ` OWNER ADDRESS �fl- �O`�` TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL PRINT ❑ RESIDENTIALQ� CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO❑ APPLIANCES 1- FLOORS-$ 1 1 2 3 1 5 6 BOILER 9 11 1 12 I li BOOSTER CONVERSION BURNER '' COOK STOVE —� DIRECT VENT HEATER DRYER, — _ I FIREPLACE FP,1'CiLATOR —� FURNACE GENERATOR • GRILLE INFRARED HEATER LABORATORY COCKS i MAKEUP AIR UNIT .-_1 OVEN --1 POOL HEATER • ROOM/SPACE HEATER ROOF TOP UNIT TEST . . i UNIT HEATER • --- • - - . • • - -. ..-••- - • -.---•• -- -• --.- LINVENTED ROOM HEATER • WATER HEATER OTHER l I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalentvehich meets the requirements of MGL.Ch.142 YES [`r'NO ❑ I IP YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE NECKING 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 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 accur e 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 I Pertinent provision of the `-' Massachusetts State Plumbing Code a Chapter'142 of the General Laws. 'Li1 PLUMBER-r FITTER NAME i 0_ LICEh�SE ` /3 SIGNATURE MP , MGF❑ JP JG- LPGI ❑ CORPORATION ❑li: PARTNERSHIP❑41', LLC❑ft COMPANY NAME 0 ADDRESS 2 6 ii-ki-r6fa q A t CITY 041-1(2-W\ TATE UST. ` ZIP 0 C-6 -7. TEL FAX CELL b il .S 3 ,2 EMAIL 0 -------- -- --------------------- ---- -------- ---- - ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT • FEE: PERMIT it PLAN REVIEW NOTES