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Home My WebLink AboutBLDP&G-24-439 MASSACHUSETTS UNIFORM/APPLICATION FORA PERMIT TOPERFORM PLUMBING WORK e47 CITY ci r1� /1 l G 1 S"¢MA DATE_ L5frj0'it PERMIT# P— 4 =L= / JOBSITE ADDRESS A a 'V"/t Yrfe r 5'f OWNERS NAME POWNER ADDRESS TEL FAX_ TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL,) PRINT CLEARLY NEW 0 RENOVATION:0 REPLACEMENT:A PLANS SUBMITTED:YES❑ Nogr FIXTURES FLOOR—, tSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE _ DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM ■ DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER ' DRINKING FOUNTAIN ■ FOOD DISPOSER I llr II FLOOR/AREA DRAIN I f, /i. % 41 INTERCEPTOR(INTERIOR) I V , f � r I ' I KITCHEN SINK I I LAVATORY - 1 ROOF DRAIN w.N Diiii ' I SHOWER STALL 1 SERVICE/MOP SINK I TOILET I URINAL WASHING MACHINE CONNECTION 1 WATER HEATER ALL TYPES 1 WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE/ TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POUCY 7 OTHER TYPE OF INDEMNITY 0 BOND❑ OWNER'S INSURANCE WAIVER:I am aware aware that the licensee does not have the insurance coverage required by Chapter 142 of the j 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 ate 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 corn ' nce with all P AirfBnt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# ,50C'3LfJ SIGNATUR MP 0 JP, CORPORATIONP# ARTNERSHIP❑.# LLC 0# il COMPANY NAME GUwe5Or►t - r i, r 6/PIP I` ADDRESSI, Iv Ka-&m 'w�"L CITY S All a r T OC f!) STATE l- ' 1\ ZIP ((46 q TEL £i o;3 715767 FAX CELL EMAIL CYe 7�1 _ &L 5 "�m/�/3 w . 0 � i4G y 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 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - =nl CITY �4 T,+✓.X�� 6�4-5)C4 �^/� MA DATE 7/�/� PERMIT JOBSITE ADDRESS O W i ej S (/ OWNERS NAME GOWNER ADDRESS TEL in TEL FAX_________________ TYPE OR RESIDENTIA OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 L[r PRINT �/ CLEARLY NEW:0 RENOVATION:0 REPLACEMENT, PLANS SUBMITTED: YES 0 NOZr APPLIANCES-1 FLOORS— BEM 1 2 3 4 5 6 7 6 9 10 11 12 13 11 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER --------1 DRYER FIREPLACE _____D FRY0IATOR FURNACE GENERATOR �-��I GRILLE ` R,� [a . INFRARED HEATER (12�T LABORATORY COCKS 1itt-i077 MAKEUP AIR UNIT ,i— OVEN LMENT POOL HEATER ( pl v,, ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER • • __ (INVENTED ROOM HEATER • WATER HEATER I - OTHER INSURANCE I have a current liahili insurance policy or its substantial equivalent which COVERAGE the requirements of MGL Ch.142 YE ]NO❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY,ET OTHER TYPE 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT 0 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 at P 'rent rows me yt Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE# J SIG ATURE MP❑ MGF❑ JP p• JGF❑ LPG(❑ CORPORATION[�# PARTNERSHIP�y� ❑# LLC❑# COMPANY�NAME —C3,✓e,'Lrn e t3 ci y 5 �I 1; /�A DRESS 7J eQ w,> Qw iy.W K--"�2 CITY 53`. Lq f'd.1QC/'r)/ STATE 4/A- ZIP C��GUUU6 CI TEL S a'�/>-�16 FAX J CELL EMAILC.drle (J r<YYvI�In �MUI` l tCony ES UG GAS SPEt, THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES ItOII �fTION NOT Yes No THIS APPLICATION SERIES AS THE PERMIT 0 ❑ • FEE: $ PERMIT# • PLAN REVIEW NOTES