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HomeMy WebLinkAboutBLDP&G-24-707 MASSACHUSETTS+ UNIFORM APPLICATION FOR A PERMIT TOTO PERFORM PLUMBING WORK CITY EJ/�/YLL // "MMA'DATE g/I/6! PERMIT JJt1Y 2v 96'I JOBS ADDRESS J 9 `1 p/2-f i�/•c1C I Uv OWNER'S NAME)i()YV7D LIe9c.Ii V P OWNER ADDRESS/9 7 S�gr/✓� l_t /T i TEL L`!" 3 ty&7 TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL RESIDENTIALLY PRINT i �.� CLEARLY NEW:12 RENOVATION:❑ REPLACEMENT: PLANS SUBMITTED:YES❑ NO 179/ FIXTURES Ti FLOOR—, BEM 1 2 3 4 5 6 7 6 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) KITCHEN SINK LAVATORY ROOF DRAIN _ , SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTIONi , WATER HEATER ALL TYPES WATER PIPING _ OTHER MSURANCE COVERAGE: I have a current liability insurance policy or substantial equivalent which the requirements of MGL Ch.142. YES NO❑ IF YOU CHECKED YES,PLEASE INDICATE TH E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 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 0 AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that at of the detaEs and information I have submitted or entered regarding Ris application are true and accurate to the best of my knowledge and that all plumbing work and'installations performed under the perms issued for this application will b 4pr rWfiance wiUa,all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. fd/lI 1{ r.n.i!/� PLUMBER'S Nr6Y`M ' LICENSE#��K.l i SIGMA MP❑ JP V J jj CORPORATK/N D# PARTNERSHIP❑# LLC❑# COMPANY NAMED iJtNL pA- Iz ® ) I'1`L� ADDRESS I..b p/9/ f,Z' t4 a CITY/-yNvi L5 STATEAI/ ZIP ©,�6Iff TEIt Cg' — FAX / CELLSdr 2q2 loi5q- EkAl apovi,G/,�CCe9i''o/CI%k- 4 f4 fJ 'r, MASSACHUSEiTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GA3 FITTING WORK Y7 PEW'# G/. •�C JO B S ITE ADDRESS ' S 1z. I hf!'�' D 1 1 -i2 A OWNER'S NAME: 7�1)i:f� �.. i C4: G awNERADDREssl Li Spy]Al it i _Tel MIA‘55C-1,5 FOR OCCUPANCY TYPE: COMMERCIAL oe •TONAL El RESIDENTIAL C CLEARLY NEW:0 REN0VATIOlt 0 REPLACEMENT:,TA PLANS SUBLIMED: YES 0 NO [37/ APPLUANCES1 FLOOR-. BFIt 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 — FRYOLATOR FURNACE GENERATOR ,, GRILLE INFRARED HEATER W LJAt30RATOlkY COCK MAKEUP AIR UNIT' .OVEN v POOL HEATER ROOM I SPACE HEATER - -4 ROOF TOP UNIT t TEST Z UNlT HEATER "U . ROOM HEATER ` WATER HEATER - INSURANCE COVERAGE 1 If you a current(lability policy the type substantial :. `,,: , which checking meets the requ{ireme�ntts.of MIGL Ch.142 YES [NO ❑ Il you have Chi ya please kdcate the t�of.. - 1:by � box bekM. LIABILITY INSURANCE POLICY fa OTHER TYPE INDEMNITY 0 BOND ❑ OWNER'S INSURANCE WAIVER I am aware that the licensee Amman=the ascsance coverage'Nuked by Chapter 142 of the Massachusetts General Laws,and that my signwtrpe on this peneitripplication ohm this requhemera, SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0 AGENT El hereby certify that all of the details and information l have submitted(or entered)regarding this application era true and ac tsate to the best of my Knowledge and that all plu nbing work and insbillations perfumed under the pent Issued for Ills application MI In compliance with ail Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME Ct 2(Z- 9,,).T,10 lit / LICENSE&2 1$-� , . SI TURE COMPANY NAME:t✓//y� , Si) L/r[i! ADDRESS:�1 / / ,S (�L� CITY• 6 / STATE '� ',�� �� ZIP:D CA FAX: TB ci - 99i- l�EMaIL v�io 4s _ l c/1'ri?c 5I i' `t' MASTER 0 JOURNEYMAN LP[WAIVER❑ CORPORATION❑# PARTNERSHIP❑# LLC❑f 3pairAiy Ei'Vr9/L, AlS : 6 (,)pieli6f ni --