HomeMy WebLinkAboutBLDP&G-18-006995 MASSACHUSETTS UNIFORM APPLICATION FOR/ A/PERMIT TO PERFORM PLUMBING WORK
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CITY/4'i c 4l MA DATE G-b ` / PERMIT#/�✓�/� �U`rr�
JOBSITE ADDRESS // /‹. OWNER'S NAME `rC/��r
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OWNER ADDRESS /3 01 / C 4IJ do /F S;c c TEL J"�/ SS--)_,FAX_
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL❑ RESIDENTIAL E
PRINT �/
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:L✓� PLANS SUBMITTED:YES❑ NO 0
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/OIL/SAND SYSTEM _ _
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR) 1 �' wI
KITCHEN SINK L
LAVATORY •
ROOF DRAIN
SHOWER STALL j 1 SERVICE/MOP SINK ` '
7±0
TOILET --11
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES r
WATER PIPING
OTHER
INSURANCE COVERAGE: L
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES t....
NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THETYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POUCY 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❑ AGENT❑
SIGNATURE OF OWNER OR AGENT
L 1 I hereby certify that all of the details and information I have submitted or entered regarding this application are true accu)ate t of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compli nce provisin of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBERS NAME Des/1 /^S"IC_ LICENSE# /3.2 c). SIGNATURE
MP n{ JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑#
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COMPANY NAME(/nn sit / 'n - iv N ADDRESS 4✓r/4 . cc5f
CITY 50-ew" - STATE /14 ZIP ,001.GGC.) TEL 2 /C 778S--5
FAX CELL EMAIL
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ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT #
PLAN REVIEW NOTES
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
`;`€#- , / MA DATE (.3 6-- / PERMIT ��'r.^ - t-evowr
�:'` CITY ,.., c, ,
JOBSITE ADDRESS 7/ / c Ir' OWNERS NAME
GOWNER ADDRESS /3,1, 4CG4otc/c i (77,gti*.-. TEL 7 5/- ?5-127 FAX
TYPE OROCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑
APPLIANCES 1 FLOORS—F BSM 1 2 3 4 5 6 7 5 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE _
DIRECT VENT HEATER _
DRYER
I
FIREPLACE — I
FRYOLATOR
FURNACE _
GENERATOR I
GRILLE I
INFRARED HEATER
LABORATORY COCKS "-- D !
MAKEUP AIR UNIT
OVEN i
I '. r4 ,t0;r
POOL HEATER l ;�
ROOM!SPACE HEATER ' ,
ROOF TOP UNIT ,__v B. 1-� 'f`r,
TEST _. : :_ __
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO ❑
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 taws,and that my signature on this permit application waives this requirement.
I
t.
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 nd accurate to ",, of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compli nc ' -a_ inen'prov€sign_ of the
44
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. > I
PLUMBER-GASFITTER NAME LICENSE# SIGNATURE
MP MGF❑ JP ❑ JGF❑ LPGI ❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# I
COMPANY NAME —'C� / S-^„h,.^ Z� /I ADDRESS C' CI ' V c (:/c/
CITY SJeai►.') STATE/ I A ZIP 0) 6 Co scTEL Y ��E-1' I
FAX CELL EMAIL
�/-f L O
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No !eL'L /?t4 e�L �a1 �C
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ /vort aG-, Z 1�14'
FEE: $ PERMIT#
PLAN REVIEW NOTES