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Home My WebLink AboutBLDP&G-20-001008 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK - PERMIT#�1 P 7-V ^ __= � CITY 2"G'P.d' �-t(� li MA DATE Vot/At:;1 �//,''�f JOBSITE ADDRESS //r �a a ,,t OWNERS NAME (3 , Cl OWNER ADDRESS . S /'h '� TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:(, PLANS SUBMI I I ED: YES ❑ NOdr FIXTURES 1 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 �I 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[ / NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LABILITY INSURANCE POUCYA 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 are true and ace = • o the •-s • y knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complian e wit. - pre �n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ,• PLUMBER'S NAME LICENSE# " f:G "� RE MP ❑ JP[( CORPORATION❑# PARTNERSHIP N.'• LLC❑# _0� '`7 COMPANY NAME // `" //e ADDRESS 9 r J/LL '( e / CITY STATE J4 ZIP G v V TEL 8 f 7 FAX CELL EMAIL rr La cp O F- v] F O U w st Z •� _ — cn O a > — o C C 0 0 I- 1 U 1 a. a. 2 L11 = W 0 z O U a., Z z a.t MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK i 1-11 `'- . o'R MA DATE / PERMIT#/.�� '05-MLA( f� �s, CITY �� JOBSITE ADDRESS/ ,1 ? / (� OWNERS NAME er ,_/d /____ GOWNER ADDRESS t5 �'�/ e TEL ��// FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL a- P rJLNT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT:[1'- PLANS SUBMITTED: YES❑ NO 4- APPLIANCES FLOORS� -� 6SI�A 1 ? 3 1 5 6 7 B 9 10 'I'I 12 '13 1 F BOILER —1 BOOSTER _ CONVERSION BURNER COOK STOVE DIRECT HEATER DRYER _ i FIREPLACE FRYOLATOR I FURNACE I GENERATOR GRILLE ! INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT l POOL HEATEROVEN C i I V E LI i ROOM/SPACE HEATER ROOF TOP UNIT �t'r 2 Mg i I TEST _. UNIT HEATER --- UfdVEtJTED ROOT`! HEATERFmar NET WATER HEATER I I OTHER � - INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of it GL.Ch.142 YES g NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY V- OTHER TYPE INDEMNITY ❑ BOND ❑ II OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 14,2 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 compli a ft all Pertinent provision of the ,'. Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE#o,a/II SIGNATURE MP ❑ MGF LI JP r" JGF❑ LPG!❑ CORPORATION❑li PA.RTNE SHIP❑/# LLC❑l#: COMPANY NAME/�{A 66 ,��/i S ADDRESS 7'r S'�L e /e- /Z (9 C' CITYYe, YI a(] V-4 STATE A - ZIP 4) 66 TEL Q` '17G' .3 V, FAX CELL EMAIL _ • rs' a- a- �24 CAsL `'' Z I 1 I i I I , 1 1 I 2 0 0 1 u . I; ! P 1 1 1 I I i I..a G I-1 [ w c 0Cl- CI Z- W = F- I aK 1— al co 4 0,4 1— a_ co u_ I I Gn j C 1 y 1 G1 1 r) 1 I I — I co I0