HomeMy WebLinkAboutBLDP&G-20-002266 #36 •
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
�.= CITY +� MA PATE � �/ PERMIT# < �o' �a
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JOBSiTEADDRESS Ji IGiG°�`'s-. X�`_" OWNER'S NAME r�/,14"; f2
p OWNER ADDRESS 4 �-�'�" '.. 1,4 TEL``'' ¢ %; . ;/-";, ( FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL[3 EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑
FIXTURES-1 FLOOR-4 BSM 1 2 3 4 5 a 7 8 9 10 11 12 13 14
BATHTUB .
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GASIOIL!SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM .__.
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN _
FOOD DISPOSER
FLOOR 1 AREA DRAIN
INTERCEPTOR(INTERIOR) •
KITCHEN SINK
LAVATORY �~
ROOF DRAIN . ,
SHOWER STALL — -° --�
SERVICE!MOP SINK
TOILET 3 '
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
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INSURANCE COVERAGE: J
i have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES IB NO ❑
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
UABILITY INSURANCE POLICY Er OTHER TYPE OF INDEMNITY 0 BOND D.
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 ail of the details and Information I have submitted or entered regarding this application are and ac to the best of my knowledge
and that all plumbing work and Installations performed under the permit Issued for this application will be In I 'nee Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws,
PLUMBER'S NAME LICENSE# f C'tS� r SIGNATURE
MPia JP❑ CORPORATION Eli 3C 1 t' PARTNERSHIP❑# LLC❑#
COMPANY NAME 6006 (-Q �i`��'rt%Lw N c ADDRESS 6 Fr9/°parrvi Pc)er—
CITY c ki4or STATE'dam(/q ZiP !.'�rk.(0a r TEL .rob'"
FAX_,51 b S c y J S 7 CELL See 93 V JQJ.. EMAIL 571 ..., N 6,rfitii`? car oC /.cL"qid
=�.._. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
apt 6 ,
;= CITY /�C -�-' ''' MA DATE PERMIT# ✓ OG'�D Ad
Yea'
JOBSITE ADDRESS .3 4 att)evz. .a'i� OWNER'S NAME t ,o,' t 0, R tJ
GOWNER ADDRESS l4 c 10''w ^TEL FAX
TYPE OR
PRINT OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES El NO❑
APPLIANCES-1 FLOORS-' 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
FRYOLATOR
FURNACE j
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM I SPACE HEATER
ROOF TOP UNIT
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 [ 0 ❑
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY LJ OTHER TYPE INDEMNITY ❑ BOND El
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 El AGENT El
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 complianc ith'all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME A i C.""ar c) LICENSE# 9610r SIGNATURE
MP"MGF❑ JP❑ JG.F❑ LPG' ❑ CORPORATION LJ 3C1 16 PARTNERSHIP❑# LLC❑#
COMPANY NAME qC Am Cod e I ADDRESS g s =tee. v
CITY STATE hi/J, ZIP 0 2 '/ TEL 3'"o j)9yf—
FAX cO4"39'f 7t 79 CELL OP'9.1$' — 7 a- EMAIL s;e:,ieckpl ec;/mtc%wr.ri`/. cv.�