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Home My WebLink AboutBLDP&G-18-006732 MASSACHUSETTS UNIFORM APPLICATION FOR/A PERMIT TO PERFORM PLUMBING WORK CITY Y9/1-00af�i/ MA DATE cailiN PERMIT#/0'/8''4067/ JOBSITE ADDRESS V-'l -[?/CYIK, OWNER'S NAME 14(f6- CyR-- POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED:YES❑ NO 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 C�`J1 SHOWER STALL T SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: C I have a current liability insurance policy or its substantial equivalent which meets the requirements of MC L . _ • IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW MAY 21 2018 LIABILITY INSURANCE POUCY4r OTHER TYPE OF INDEMNITY 0 BOND❑ BUILDING DEPART ENT OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage regtlr ti by Chapter 142ofthe Massachusetts General Laws,and that my signature on this permit application waives this requiremenL CHECK ONE ONLY: OWNER 0 AGENT❑ SIGNATURE OF OWNER OR AGENT ill I hereby certify that all of the details and information I have submitted or entered regarding this application am 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 pro ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,.Y'/`o.,,'..^. PLUMBERS NAME LICENSE#/�18s-g r� S GNq URE MP bJ JP ' CORPORATION IS41 PARTNERSHIP❑.# LLC❑# COMPANY NAME I•`LO' L( 77,f/6 9L LJ,(/6-- ADDRESS 30 /SS/4- � CITY ` '¢�/hd N STATE p(� � ZIP n 7a TEL 73? FAX CELL,_5~-AI_ EMAIL !6" 11 I ? eg Z/eff ROUGE PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT # PLAN REVIEW NOTES 1-3 '` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK j I»�'J - : CITY y f l e.(V)Q`I MA DATE 1 al lie PERMIT# 1---dk13-410 6712 JOBSITE ADDRESS LF-1 «11DV-_. OWNER'S NAME n GOWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Ix- PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:4 PLANS SUBMITTED: YES❑ N0gr APPLIANCES 1 FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER _ DRYER _ FIREPLACE 13 FRYOLATOR FURNACE GENERATOR - GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM;SPACE HEATER 4ROOF TOP UNIT ( J TEST -' UNIT HEATER I`° UNVENTED ROOM HEATER .`:"_"1 WATER HEATER ( OTHER 0 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. It. F ::;:t ;* „O I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY < OTHER TYPE INDEMNITY ❑ ND ..;a OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage require bit .!" TMENT Massachusetts General Laws,and that my signature on this permit application waives this requirement. y ` ==--- CHECK ONE ONLY: OWNER ❑ AGENT ❑ L 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 Pc' nent pro is n Ile Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4-TVA PLUMBER-GASFITTER NAME LICENSE#/ d. SIGNAT ;,E MP'MGF❑ JP'JGF❑��,//L�P,�GI ❑ CORPORATION'# PARTNERSHIP❑# LLC❑# COMPANY NAME �'i'C.. /4/0777i -J-c Ldn✓C_, ADDRESS 3o mews-3-4--- $.2/(/(y CITY 5(6 k--M v1--1 Wl / STATE Mk-) ZIP 0 6"--) -. TEL 5Z0 -73 7 c)461 FAX CELL EMAIL C."►q C. L/3 )-6111 /(,,C.pm ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT 11 FEE: $ PERMIT# PLAN REVIEW NOTES