HomeMy WebLinkAboutBLDP&G-20-001983 • $„ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WOJ6
k!". -j_y= CITY/TOWN &OP,,S-> 1 RI) of/7y MA DATE /) l 7`/ PERMIT#/PIS 6 W
JOBSITE ADDRESS 31 ill i/'h 4 IKAJ 1l--0 OWNER'S NAME 74/4i0 /724C41y
OWNER ADDRESS • TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: a PLANS SUBMITTED: YES ❑ NO[✓
FIXTURES 1 FLOOR BSM 1 2 3 4 5 I 6 7 8 9 10 11 12 13 1
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 i
LAVATORY
ROOF DRAIN
SHOWER STALL
SERVICE/MOP SINK .
TOILET
URINAL _ •
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES / _
WATER PIPING
OTHER
y
INSURANCE COVERAGE:
I have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch.142. YES("NO 0
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY (e 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 ❑ 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 knowled
and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. t
PLUMBER'S NAME Br AA) )1 P--e1 LICENSE# //q7 7 SIGNATURE
MP +Q' JP❑ CORPORATION PARTNERSHIP❑# LLC❑#
COMPANY NAME CA PI. CA) PAM,601 4-Alter Tit ADDRESS / . D s z1 D X
CITY Sj y4 pf..J..di,f' STATE /17,1. ZIP 0 a. 6 4 0 TEL SDP-3S8- Z 22.P
FAX CELL EMAIL Ca/at diekrhbt @ Liao,-G,
( S 3D7 cc)iP -
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY t ij r7 Y 7y27 /7/ MA DATE /� 7/l I' PERMIT#, /IMP 0l0-M;SI
JOBSITE ADDRESS J( L )//h, / Ai / OWNER'S NAME J /;///,/o 1 74 rxiy
GOWNER ADDRESS TEL FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: 0/- PLANS SUBMITTED: YES❑ NO❑/
APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6_ 7 8 9 10 11 12 13 14
BOILER
BOOSTER _
CONVERSION BURNER I _
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE ,
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN _ `
POOL HEATER _
ROOM/SPACE HEATER •y ' , •
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER j
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [P0 ❑
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 all plumbing work and installations performed under the permit issued for this application will be in complian with allth Pert of the
Massachusetts State Plumbing Code and Chapter 142 of
the General Laws.
PLUMBER-GASFITTER NAME ,L/.44 ,7` d cam; c c1 LICENSE#1/977 SIGNATURE
MP[2MGF❑ JP❑ JGF❑ LPG' ❑ CORPORATION P# PARTNERSHIP❑# LLC❑#
COMPANY NAME CAI.O(. CO d P 44{ t Al G, ADDRESS P. 6 . zx 'i Z
CITY Spti7I 1) 4/A/>1' STATE ZIP D 2 6 46 TEL Sax
FAX CELL EMAIL Ca1147e.G-)cir/um 4i l .et5 et,
c O 3307 J-Z sR/51