HomeMy WebLinkAboutBLDP&G-18-004512 (^ µ'�, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
i—,L CITY S 0,,,;-,` P.
. /2.:,/vik -4 MA DATE .2. l//f PERMIT# /,AP
1 /,;JOBSITE ADDRESS / 35- t L_ e_/t /&d OWNER'S NAME; /' �.41/' _-' /TG,-
POWNER ADDRESS I TEL; FAx I
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 7 RESIDENTIAL -- . 00
PRINT
CLEARLY NEW: 7 RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NOS,;
FIXTURES-1 FLOOR-• BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB 1 ( q' 1s
_' V rr`- ..-: ,11_ _ f +/t..._.�1, R . ♦ �\ r A t. t•rW
CROSS CONNECTION DEVICE .1� __ . ._ JY
DEDICATED SPECIAL WASTE SYSTEM �' .., 11 d ;' i..Li. _._ '_ . i _ .. �;. I _.
DEDICATED GASIOILISAND SYSTEM i - 1 ,, 1 #i °
DEDICATED GREASE SYSTEM y
DEDICATED GRAY WATER SYSTEM ,11 , ,�-- 1 '
DEDICATED WATER RECYCLE SYSTEM I il ii , ;! . ' _ , .1 _ i _ �� , -
DISHWASHER
DRINKING FOUNTAIN fl,- _. �. 1
I
FOOD DISPOSER
w.11 717 7. ..._. ( X 1 A', ,' V' 1-. -.' .;Y 1/ 11 J PI / I r
FLOOR I AREA DRAIN
INTERCEPTOR(INTERIOR) t 't. _. _ ..._ - _ _' ? �i , _ i ��
KITCHEN SINK 1 I
LAVATORY i 7a. . LLI i J d
SHOWER SROOF ITALL _ I ® _ ,1 __ I ._ r ,
n
SERVICE I MOP SINK s 1 1 t
TOILET _ I @ .. , i . y 1 .- i _
URINAL i v ., . I, 7-; -- _-, ,S t $�_
WASHING MACHINE CONNECTION f ' I / '1
WATER HEATER ALL TYPES 1 - _, _ , t
WATER PIPING I 1 i i 1 ..
OTHER . �i_ `� !...
JJ
i 1 ti. ' 1 f ',.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES LL,j NO i
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY f „r OTHER TYPE OF INDEMNITY , 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 AGENT n
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 corn • h all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �
PLUMBER'S NAME I3 r I J 1 i b bA r cI 1 LICENSE# I!y'77 SIGNATURE
MP' JP i ,j CORPORATION #i r JPARTNERSHIPT# LLC JJ#
COMPANY NAME IC/401 L d_ J 1,jj pis 1-BT1 ADDRESS; 1'-.0 . 1 D,x N Z 5' 4
CITY, 5. J ,J ia r .f i STATE /7 - f ZIP i D a A /_o j TEL II? , j S7- Z 2 Z ,
FAX CELL EMAIL
i 3 s
i�
liZz. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
'•=' ;- PERMIT#/a�l�P/�T- '
.az_� MA DATE � L _M_ -
ed
t_, CITY _._..__ t;J-:.7 .-- __ ._._..._
•
JOBSITE ADDRESS ./. ..3 ... , �,e_...A,.6't..__ OWNER'S NAME " _41,/ __012.: .... ..
G OWNER ADDRESS
TEL FAX
TYPE OR
OMMERCIAL �`' EDUCATIONAL _ RESIDENTIAL
PRINT OCCUPANCY TYPE C _
CLEARLY NEW: ._.. RENOVATION: _._ .. REPLACEMENT: .,1"......, PLANS SUBMITTED: YES NO
APPLIANCES Z FLOORS-0 BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER _..__.
BOOSTER ___ ....; ._ _ _ _ _.. . _
•
CONVERSIONBURNER -.w_: _._ .. _. : _. . ._.. __.__..._ _,.__._ _.._..__... . _._.._._ .. ..._...__ ....._._..... _..... r _._...._.. . ......_ ..._ _. _.. ,_.
COOK STOVE
DIRECT VENT HEATER -_. , .-_ ...____. -_-_- _-�..__�,. _.. , _ . _
DRYERM.._...._, ..-..._,_ :: _...__.....,.� . ._. .....� _... _..._. ..__. _.._._..._ , _.. .._..
FIREPLACE _._._
FRYOLATOR
FURNACE _._ .....__... _..__._ _...� __..0 _.... ..... _..__._.. _ ....__. _. _
GENERATOR _.____
GRILLE „,...._�.b , _._...: ...._._. . _ ,�.._.: .,..__._..._ .
INFRARED HEATER
LABORATORYCOCKS ___.._ _ _ .____._ .____,_... ._..___ �._ _. _ ._.._: __-.._-. ._....._._.. ._._..__ __. __ _.._. .._....�_._. ._..._
MAKEUPAIR UNIT .� ..____ ., ._._.._ `,_____._...a __._._.___.: _._.. µ:�� ..__ ,_.......�.z _...__._. _...
OVEN _..__..____ ._...__ . . __. ..._._._.. ______ _ .rv_._..A.. _._._. w;.. ._. . `T.:._. �:. _ . . . __ .......... , ..._._.._.. _._ ... .
•
POOL HEATER _ ___ _ - _% _w.__ .... _...M , ...._. .... ..._. _. ..... _ _.__
HEATERROOM I SPACE EA . _� � ..__... _ ......_. ..-. . .. _.__K_ .... ..._.._ ._...__. ...__..__.....
•
TOP UNIT __ ___.: ' � �._.� �_. __._.' � _ _ _._. �._�; . . f .. --� M._-_-_. ..__
ROOF 1._
TEST _.-._. .,. __. __ _._ _.k _.._ ___ - _ ., .. _._�_. ._...__ .. ..• :._ _.. _. ..__.._.. I
U N IT HEATER -- __�_ _.__._.. _.. _...._.� _ _..._ _......._.._.._ .. . ? •T = r -'i _ 1`
UNVENTEDROOM HEATER - _.. __._.._.. �..___ ._.._.._._ __ ..__.._. , ..v. ___. ._._._.. , ..___. ._. ..-
WATER HEATER
OTHER _........._._-, ........_. , -........ . _....._ _._...._
. .,__.......__., --_...._._,w___. ._._...,..._,.__......w__.�..,._w._. .......__, _ INSURANCE COVERAGE - ..... .....
- 142 YES �0 .. .
I have a current,liabiliity insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
•
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ., . 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 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 accurate to the best of my knowledge
and that aH plumbing work and installations performed under the permit issued fOr this application will be in compliance with a Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. , ?
PLUMBER-GASFITTER NAME fir 1 / ,tiJ id r be,.,.. w_- LICENSE # 119 77 SIGNATURE
MP ✓' MGF JP JGF ._, LPGI CORPORATION V# PARTNERSHIP _..._ # ._.._ LLC ._..:# ,..�._.__. _._. .. .
COMPANY NAME: C- i ES Lo �' �r t . TADDR S r. D iyx
CITY jT / /tj .____.. ...__... __.-._....._____._._.___.. STATE ft* ZIP ..a_L 6 6 ___w. TEL _, 0,"%ori/- z a.?F. ___: .
FAX CELL EMAIL