The URL can be used to link to this page

Home My WebLink AboutBLDP&G-20-005858 ; IC\ p 1—cA ce_ I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK WOE (-*'' CITY Q, UU4V \ MA DATE <1 1 ?0 PER nT# P 06-337- JOBSITE ADDRESS 3 ✓?QI�.J�/�(//�L(I`1 IN (( /1J OWNER'S NAME i t. c O OWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL] PRINT CLEARLY NEW: ❑ RENOVATION:❑ REPLACEMENTt PLANS SUBMITTED: YES❑ NO❑ FIXTURES 7 FLOOR-0 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 I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 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 TSL 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 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 complia ith all Perti provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME C .6 P ;act e I I LICENSE# '� ,?�� SI ATURE MP JP❑ CORPORATION ❑# PARTNERSHIP❑# LLC❑# COMPANY NAME Cc-r I F. IR, e d I I t 5 ADDRESS 77 1\1 a rm t r e CITY v S T e r v i l\ e STATE iVI/-1 ZIP `jam TEL 5 - H - `o 3(, FAX CELL EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ? f = CITY __... n�..lLY:L..�._'. .-.. .._ ....._._..._... - MA DATE . _II. L�, 1 PERMIT#1, ✓?D�57✓`'S7 JOBSITE ADDRESS 7.1 ._- ....AM. ..�j.1A.J..__.._ ail OWNER'S NAME _ ___Ifrhk+'c _. . . ._ .... ..-. G• OWNER ADDRESS .' TE I _I FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 1,__I RESIDENTIAL PRINT CLEARLY NEW:® RENOVATION:Q REPLACEMENTS• PLANS SUBMITTED: YES 0 NO APPLIANCES 7 FLOORS-+ BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 • BOILER BOOSTER 1., ill__ i__.-._it_n_ I__J1 _„.._. 01 Ii 11,__ :i _ _ it _ I_____II__ I _ CONVERSION BURNER - I 1. I Al___ I_ _ _. FI -_}(- I:_-- '. w_._ L__. #l_--_J' LJ COOK STOVE I__ !__._11_-.-_ 11 'I _ -;_ - __.._II ___._it_ _. '..____.I DIRECT VENT HEATER I =' DRYER !._-.__.. L_ I._. i__.�. l_, ._II___ _.mi_ ei{...... _ 1I,__ - (—__._,_.1',_,.__.__.IIi._____..,11,.._..._._, '.____._ 1._ __ FIREPLACE i l EI rf 1 ,..1_, sl 1. i' FRYOLATOR -__ _ - tt FURNACE GENERATOR _ GRILLE I L... - _ ? 7:_ ....=f i..._ II....._ li _ il . 1' It .. II:..- Ft, t INFRARED HEATER I I--- -- 1 - ' I 7� 1 i 4 LABORATORY COCKS ;_ ',1.. . -- F tl .� "I _( i t MAKEUP AIR UNIT 1- 01 ---1 _. .I i 1 : ,_ __. 11 =1 :. ._. OVEN ii POOL HEATER ._.._ "-- -_ 1— 5 ri ROOM 1 SPACE HEATER i _.- !.. ii L_-,_ =S i - - ROOFTOPUNIT i 1 1!_� _;I ' i,' -13 �I.._.. ..! i i, �.._ =1.-- t TEST ' i = i UNIT HEATER i 1, I__ ,I_ - i lll :I lil 'I ._ I i _ . i ,_.. 1 !.. i UNVENTED ROOM HEATER f _:.1:. IS-,._ . _€l_ .- ! Fi Ii . I .7.11..... 1^. I _ i � WATER HEATER f f'- -..".._ € v -r _...i3 I _ ...,-- OTHERS i ;!_ !I_..._ II__:__ 1 . fl i _ l il :I 'l fii i INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES EINO D I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY a OTHER TYPE INDEMNITY 0 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 L 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 complia ith all Pe ' t provi ' he Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME _L c,r I P : cl e I l _' LICENSE#= y6, SMATURE MP IA MGF JP El JGF LI LPG'El CORPORATION L.j#I_ 1 PARTNERSHIP 11#_ LLC D# I COMPANY NAME:1. c_r-I___I __._hi e d e I_.f._...r....Son__I ADDRESS -7 7 8...._..._I�'S_ ..�n_:..__.Stre e __. __._._..__._.._--.__._____._..-.__ e. CITY U5 ' r II - ....._.__. r ... P aG5 TEL 5(._) - ya : Cp 3Co5--_._ _ _. _____._ ___ _ _ TY FAX . ._.._.._.._....- 1 CELL ,EMAIL