HomeMy WebLinkAboutBLDP&G-24-499 RI ECEIVEDI
MAP.' �0M2 a�-C ! I MAY 212024
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A7ASSACHUSE7T8 UNIFORM APPLICATION FOR A PERMITTO P 6tigJt5Pa
'= crrYI Yarrrni)i-h I MA DATE ,7;i/Zfi PERMIT#4LDP-iti_1-Il'9
JOBSITE ADDRESS 77 17•a ste 2R OWNER'S NAME Rriarr g.,Crnttls
i OWNER ADDRESS I I TELI 'FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL❑ RESIDENTIAL 0
PRINT
CLEARLY NEW:(2( RENOVATION:D REPLACEMENT:D PLANS SUBMITTED:YES❑ NOD
FIXTURES 1 FLOOR-. BSA 1 2 3 4 5 6 7 6 g 10 J 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE '
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS&OIUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM M MIK p.—
DEDICATED WATER RECYCLE SYSTEM NM 161111 MN AMP 0IIIII MI
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL " mini .
SERVICE/MOP SINK •
TOILET
URINAL
WASHING MACHINE CONNECTION I
WATER HEATER ALL TYPES
WATER PIPING
OTHER '
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INSURANCE COVERAGE:
I have a current Jiablllty Insurance poky or Its subetantlai equivalent which meets the requirements of MGL Ch.142. YES 8-NO D,
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY e" OTHER TYPE OF INDEMNITY❑ 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.
CHECK ONE ONLY: OWNER❑ AGENT ❑
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 emirate to the best of my knowledge
end that at plumbing work end installations performed under the permit Issued for tills application will be in compnarrce with an Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
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PLUMBER'S NAME I 4;4,'4/s.'`A e f/!£r-74 JUCENSE#I/�TeX`/I SIGNATU •
MPE JP[J CORPORATION 2# 3. 3`7 PARTNERSHIPQ#I ILLCD#
COMPANY NAME A/l gam/A7y /J-74 A(.2,C. I ADDRESS %/(7,.. "0 „j 7--
CITY AT�-id.erriZ'.f, 5-1 I STATE Lfl I I ZIP I U7A? I T L 77y �- s‘a74Y J
[AY I I nsrr r I I cuum I CC/Li'J77 X- 7 QQk Co
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_� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
'--,---- ----::114 2._;-1--) CITY . _v ____ _____ - - ---• - 'C 0 P-Z'•-I _ cl i'l
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--.. 1� t►'k MA DATE ‘.51z l/Z�4 PERMIT#
JOBSITE ADDRESS f 71�Abu I' 2� —_�_:_--_I OWNER'S NAME :.rr� 8, srnLrh I
GOWNER ADDRESS i --- �.T__�_ .I TEL . .FAX'
TYPE OR OCCUPANCY TYPE COMMERCIAL;
PRINT
RESIDENTIAL I;
CLE RLY NEW: RENOVATION:U REPLACEMENT:J PLANS SUBMITTED: YES f j NO J
APPLIANCES 1 FLOORS-, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER .-__J�J_J 4____ —1____ .. _L __I___-1 r f_J_i
BOOSTER ;—J_—I 1; 1 I CJ' _J—J__II . ..f. . . I_J
CONVERSION BURNER ._( (_J I. }: t_� 1_J:�_ I'—J,=j. I
COOK STOVE :__I .. --t —j—� .-_-_-_4—).-1`J•- 11-J .Li .I
DIRECT VENT HEATER -I__}—I_1 _J_J I_ I 7:-.1_�_J_ I:_L1
DRYER• :—J—J -.LLI_J—J --I—J; f_J• l-J-1--J
,. ,-1—I_J I_ I.___-i:_J i__J I
FRYOLATOR —1- 1 !; 1 t-. -I..__I—J.f__I ___LLD f _I—.I—1
J FURNACE ._I-J-�: I_ J. I _1 .—J—J: I I 1`—f
GENERATOR I t [JJ_J_�—J __1_1____I_J_—I_J__i' '.
-
GRILLE —J. ... - I�J_ _LI L ..I` _ 1_-1._J I—J_.1._J _J . 1
INFRARED HEATER _i I' _.. .I —_.I'__ 1 —_I-.—I . . I_J.—�—1__I,
LABORATORY COCKS . ...1
. 1-. _i�-�._J 1�.1._J__._J_,.;_j.—•f. I_J-1
0. MAKEUP AIR UNIT i ILL. 1_—I_.-1__I I_____I__I_____I ___-J_1__I�J:-J
Lib OVEN __I_I . i.:.- .. . _i —_rI. I __1_J,'�J___J__I__._J _I
16 POOL HEATER _J rJ_ __ _I. ...__, _J•. _-1—J J,_I ._I, •I_LiROOM/SPACE HEATER I
ROOF TOP UNIT ,"1 ! _1. J _I___ I_'• I�J_1__I'__1 I
TEST _.___I_____I Ir
1 ,I__J_J,_i I___i I 1 I
UNIT HEATER I_LI_J . I I ' I__J_J.__ j_J i__11: r I�J
UNVENTED ROOM HEATER __J I i I_____1_____I ; i . I JJ__i_J____`J I I
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WATER HEATER - - --- ___ _ Air I .. _ t... . ;__I I . I _____I_____I . ,
I I� ,J J 1_J 1, I
OTHER = • ...I I- , . _.' ._I_. I I_J L____J--J__I_-J-J —I
I-�-- I I—I I _ I L_i 1 -J _J . ..
I_ . • I_I "_I._ _,.J.__J I—1__I-_I__J - I_._J -
1_ .I _ - 1 . I : I , . i._j I.___I i.ii, •
ib INSURANCE COVERAGE _
b I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES I O ;J
L I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ' OTHER TYPE INDEMNITY 7:1 BOND r
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 '^I AGENT :J
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 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 General Laws. 0
PLUMBER-GASFITTER NAME', ,I/y._,Tfd/l�___ (LICENSE#,,egaq 1 SIGNATURfree.
MP MGF r1 JP JGF J LPGI J CORPORATION` #'. .23? (PARTNERSHIP:itLLC #z
COMPANY NAME:•/9// /�r �// j C 7 ADDRESS /7 /31f V
CITY /l/ Qom/,/a it ._... .. ...... .... - I STATE"la 1 ZIP. d.,2675 TEL 7247-Yi4-37 _
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FAX 1 CELL: EMAIL �E /I�O•�1G���r � ���
MAY 212024
B U IL i'1 t/U? 1.4
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT LI ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES