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HomeMy WebLinkAboutBLDP&G-20-003366 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _ i c CITY/TOWN G t rt y a2lUu,,,f 11 MA DATE 11 " 17 PERMIT#0/-1)/1-070 JOBSITE ADDRESS I ! StuilA'j1-O ItZe,A'� c ael WA�� A^�OWNER'S NAME A � OWNER ADDRESS 5 TEL SS)' 10' 6.2-*AX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL cg PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: I1 PLANS SUBMITTED: YES❑ NO [V 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) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL 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. YES M NO ❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [ ] 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 ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application e true and aur to to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in om lance ,,��h I Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME MAC(' LIA2t- LICENSE C fO"yS 1 GNATURE MP❑ JP CORPORATION❑# PARTNERSHIP ❑# LLC❑# COMPANY NAME kin 4-C, A 1. IJ ADDRESS Spy 6 C,\&t.`' qI '1 (1AA'" CITY E(.Vz.3-1 Fa� cu��E U STATE P ZIP 64 53 c TEL 17 q' 0 • Ll i13 FAX CELL EMAIL A `1C-S. lumgiC._ C-UMC9i6.1-, �,�T MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 11=1` CITY ,iC;a7 H 'jfr2A10A1 H MA DATE 1)` 8 I PERMIT# ffd`e- �1 JOBSITE ADDRESS I l I% 0 1?C.41 p OWNER'S NAME N CA14 s UtVUI P!I GOWNER ADDRESS SUM e TEL So' 7 b'SS- 9 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL La PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT:E PLANS SUBMITTED: YES❑ NO APPLIANCES 7 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 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 4 OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES El NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Sf OTHER TYPE INDEMNITY El 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 ar tr 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 m lance A'th, ll P rtinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. G,, PLUMBER-GASFITTER NAME LICENSE#'3'„2(. SIGNATURE MP❑ MGF❑ JP© JGF❑ LPGI ❑ CORPORATION ❑# PARTNERSHIP❑# LLC❑# COMPANY NAME LA'Nit. MAILI, ADDRESS J(vci t5 Cortn1,a)-0. S\nce VCA9 CITY V/�0 CuI UAuoti- STATE ZIP 09.5-3(0 TEL /il Ll" 3el)` FAX CELL EMAIL ) A(ILV(Ak12 C CCU)\C( " ^, rZ