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Home My WebLink AboutBLDP&G-24-634 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK =;mac —�— CITY 5/1 v `1 rrYl G u 1 MA DATE / y r/ I ��'�.7�'�l PERMIT HCDQ-Zh_ �3r7 JOBSITE ADDRESS g•'1 Keel Care/pNN)UO/ OWNERS NAME OWNER ADDRESS 50YI4 f/ TEL 07-957-Woo FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL-0 PRINT CLEARLY NEW:❑ RENOVATION:0 REPLACEMENT:3X PLANS SUBMITTED:YES❑ NO'% FIXTURES 7 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/OILISAND 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/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES _ WATER PIPING OTHFR,., INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YE' NO❑ IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW UABILITY 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 0 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 an accurate to t of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compile wi II P provision of the Massachusetts State Plumbing Code and Chatter 142 of the General Laws.DP PLUMBER'S NAME/.Ord J" l0` LICENSE#3,11/ . SIGNATURE MP❑ JP> CORPORATION❑# PARTNERSHIP❑.# LLC❑# COMPAANNYNAME/ ig- fiU �lJ /9 ADDRESS $y �lY LI1P/ CITY IY/KV"1CC� J STATE. A 04 ZIP TEL L TEL 6d ry7 yTy3 FAX CELL EMAIL �OI YIP 1V.{5) kf/ aIIYIQ�.CCJWI ROUGH PLUIVIBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT It PLAN REVIEW NOTES 7 r MASSAC USETTS UNIF RM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY / OU MA DATE 7 o) I PERMITi �CDO-2`-`D`7 JOBSITE ADDRESS a Keel (i pi z ,J('I i1 L OWNER'S NAME OWNER ADDRESS SCllv)Q/ T TELFj/7-9S7'167C15 FAXTYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL 5. PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT. PLANS $SUBMITTED: YES CINO APPLIANCES Z FLOORS-4 BSM 1 2 3 4 5 6 " 9 10 11 12 13 iF BOILER / BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS - MAKEUP AIR UNIT - ll OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER • -- INVENTED ROOM HEATER WATER HEATER - OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MU-Ch.142 YES" 'NO 0 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY-0 OTHER TYPE 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 0 AGENT 0 SIGNATURE OF OWNER OR AGENT �• I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accur' he best of my knowledge `- and that all plumbing work and installations performed under the permit issued for this application will be in com co Massachusetts State Plumbing Code and Chapter 142 of the neral Laws. P rtinent provision of the LEI 1_ PLUMBER-GASFITTER NAME Lrxne� J uSs)01 LICENSE#367( SIGNATURE MP❑ MGF❑ JP14 JGF PGI L� PORATIDN❑A PA/TTNERSHIP❑# LLC❑# COMPANY,/ NAME/�J 19I UjA'] f ! cP ADDRESS gL/&xj CITY/7G(t J ICh- STATE_ ZIP�- _, 5 `/ TEL 0 -77 - 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 • • • • • • •