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Home My WebLink AboutBLDP&G-19-005792 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK I t1- CITY/TOWN I0G 57 y4/1421ou7 ,/ MA DATE ,3�Z/ I/f PERMIT#dam/7-/P-cG'5711- JOBSITE ADDRESS 6.3 LI)t'N /.aJ 'L c (AJI OWNER'S NAME A''A--XXy tzQ✓c/:, OWNER ADDRESS • TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL 0 RESIDENTIAL t"-- PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED:YES 0 NO FIXTURES 1 FLOOR—. NM 1 2 3 4 5 6 7 8 9 10 11 12 13 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/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN — ' SHOWER STALL SERVICE/MOP SINK TOILET , URINAL i1(Si WASHING MACHINE CONNECTION WATER HEATER ALL TYPES / • WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESEKNO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY�" OTHER TYPE OF 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 CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT 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 knowled and that ell plumbing work and installations performed under the permit issued for this application will be in compliance wi all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME B 2I. 4/ t►t�74)A f d LICENSE# I 1 g 7 7 SIGNATURE MP[r JP❑ CORPORATION 131 PARTNERSHIP❑# LLC❑# COMPANY NAME C CdJ PI&/ib6i,, t/Ics,41 ADDRESS 7 6,d6 X 4 2 QQ CITY SOJ 7 2) 4,1si,r STATE/924 ZIP b 2 6 6 6 TEL 5-0,—./f —Z Z Z/ FAX CELL EMAIL MASSACHUSETTS UNIFORM APPLICATION FORA PERMIT TO PERFORM GAS PITTING WORK R t i CITY l�(/c.S� /.�1 ,�.�rv,�� MA DATE 31z IiS PERMIT*A-P�/1�-4wr7 9-2,2,� JOBSITE ADDRESS ( 3 LA)C.,✓ 'Q Cr)4,y OWNER'S NAME /671/ ;�� C- OWNER ADDRESS TEL FAX r rr TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL Lam ,co PAINT CARY NEW❑ RENOVATION:0 REPLACEMENT: Et' PLANS SUBMITTED: YES[a-NO APPLIANCES Z FLOORS— BSA 1 2 3 4 5 6 7 8 9 10 11 12 •• 13 BOILER _,BOOSTER CONVERSION BURNER MEM____ COOK STOVE — DIRECT VENT HEATER Min. i DRYER �� FIREPLACE _--_—�_ M M FRYOLATOR • _— �� FURNACE —_I�® �� GENERATOR GRILLE _—�MIMI � . INFRARED HEATER _��N LABORAT.- COCKS MAKEUP AIR UNIT MEIN � OVEN I , =MN POOL HEATER _r® i • E rii rilaii ROOM I SPACE HEATER �r��'j. l MI ROOF TOP UNIT i_MM. TEST - MIIIIIIIi�� UNIT HEATER UNVENTED ROOM HEATER WATER HEATER IMMIIIIIIIM��___ OTHER M _ �� .,. MEM INSURANCE COVERAGE .,,/ I have a current MEW SWIM,policy or Its substantial equivalent which meet the requirements of MGL Ch.142 YES L�H0 C I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 2 OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am a m that the licensee gavial=the insurance carerags required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application aim this requirement. •4, CHECK ONE ONLY: OWNER 0 AGENT. SIGNATURE OF OWNER OR AGENT ••• • I hereby certify that ad of the deans and information I have submitted or entered regarding this epplication ate true and accurate to the boat of my kno% and that au pfurhbIng work end tnatellabons performed under the permit Issued for tills application will be In compliance all Pertinent provision of tt Massachusetts State Plumbing Code and Chapter 142 of the General laws. %-e.NAME M ri R,,, /-f, e Joe,r-j UCENSE#1 I977 SIGNATURE MP[/MGF❑ JP❑ JGF 0 LPG!0 CORPORATION El PARTNERSHIP❑# LLC❑S COMPANY NAME CA 4J !flamer,.,( f)iiT =4 ADDRESS O. /S&c 41A CITY S jury if STATE _ ZIP 0 2 g g e TEL S e P- 31, -L g FAX CELL EMAIL