The URL can be used to link to this page

Home My WebLink AboutBLDP&G-24-555 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING G WORK • CITY ( )n. / !(-vv.) (7 r/ t-'( MA DATE 6 77 v�r PERMIT# % t ' N"S$jam JOBSITE ADDRESS /6 co dI C.t r- N-eIJ / OWNER'S NAME /1r'l i74 c<l I p /() OWNER ADDRESS OTEL 7 S 7r/U FAX_ TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL, , PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:' ` PLANS SUBMITTED: YES❑ NOM 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 I AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL _ SERVICE 1 MOP SINK R E; ��{F TOILET 6, / URINAL � tUt4 WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER 3,, INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES rk NO❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABILITY INSURANCE POUCY (� 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 L.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 Plumb'?Code and Chapter 142 of the� General Laws. PLUMBER'S NAME M I CA4C,t N L A 3 I C(( _ LICENSE# 17&0 • SIGNATURE MP❑ JP® CORPORATION❑#p P- PARTNERSHIP❑.# LLC❑# COMPANY NAME ME (NA c)`,r1 (Q Q ti' �4- ADDRESS 37 �--('�^ /1 [pQ.,7e4.0.42 CIT Y (q-� G r1.r1 I S STATE ZIP O ? Q / TEL 7 7//7--/J !I z FAX C CELL �I EMAIL STT/lj ei-- Mcr3 rec(lp jdnd-IL.(,),,, ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT It PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK Ta <' s CITY _ MA DATE 4PERMIT# r — L1 —��1 SSS JOBSITE ADDRESS / [1 �/ G jTl 7-- OWNERS NAME4(`l q1c} SCO f-111J OWI�IER ADDRESS �Q TEL 73 S 71/10 FAX, r TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL / PRINT ❑ RESIDENTIAL CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NOR APPLIANCES 1 FLOORS-I BSM 1 2 3 4 5 6 7 4 9 10 11 12 B 13 1�'OILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER -� DRYER FIREPLACE FRYDL.ATOR FURNACE GENERATOR GRILLE INFRARED HEATER H LABORATORY COCKS MAKEUP AIR UNIT OVEN - - POOL HEATER . ROOM I SPACE HEATER ROOF TOP UNIT TEST ..EE C E I V E D _ .._. UNIT HEATER r � �}�UNVENTED ROOM HEATER .,' r7 2C2'7� (�'_-� WATER HEATER ,s 1 OTHER BuIL—DING HEPAJy4IMEVF - 7 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO El I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY 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 my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT -1-• 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 Genera Laws. W473 PLUMBER-GASFITTER NAME C M 1343 LICENSE# SIGNATURE MP ❑ MGF❑ JP V JGF❑ LPGI ❑ CORPORATION❑# P COP PARTNERSHIP 0 # LLC❑# COMPANY NAME 11 " j(/� C I (Q Q { *41 ADDRESS .3 f ' �1 . CITY C G S STATE i - ZIP G. ?1 / TEL 7 7 y ?/Q ?i z FAX CELL EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT • ❑ ❑ • FEE: $ PERMIT# PLAN REVIEW NOTES • • • •