HomeMy WebLinkAboutBLDP&G-20-004655 - g . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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L� - ;: CITY 10 A�YI.[1 Y1 k ...t..._ _ MA DATE{ 1 PERMIT# �l�)/ 2O CO
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JOBSITE ADDRESS t RcVY�i.KY�l �� OWNER'S NAME @�{
/� OWNER ADDRESS 1.p _-a _. ._._ __:.) TEL 313.5 c� 'Z S I FAX I
TYPE OR OCCUPANCY TYPE COMMERCIAL I j EDUCATIONAL Li RESIDENTIAL
PRINT
CLEARLY NEW:U RENOVATION:` ' REPLACEMENT:1 PLANS SUBMITTED: YES is j NOL 1
FIXTURES 1 FLOOR RSM 11 2 3 4 5 1 6 7 8 9 10 11 12 13 14
BATHTUB If (i -. A
CROSS CONNECTION DEVICE l _ ! p f ' 1$1, '
DEDICATED SPECIAL WASTE SYSTEM MIN i I _ `` I Ii MI 111111
DEDICATED GAS/OIL/SAND SYSTEM 1 ,$. 0111111 010111111111111NM
DEDICATED GREASE SYSTEM IIIMIIIIIII.141 IMO aiiiillet 01010 IMMO 0101 N 000 NMI.ION
DEDICATED GRAY WATER SYSTEM 1 '
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DEDICATED WATER RECYCLE SYSTEM
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DISHWASHER ! ' { ,- _
, MEN 1111110.1 IMP
DRINKING FOUNTAIN T' a - Nit a NS II MI Inn
FOOD DISPOSER _ inn Immo I MINIMN ems ems ion INN
FLOOR/AREA DRAIN imp one ono mmt
INTERCEPTOR(INTERIOR) t a;: i.
KITCHEN SINK inillifili011 Niarillin NM 10001141.00t I>t 1 'Tsow ion mow
LAVATORY ' MNNM NMI 0.
ROOF DRAIN , . NM a
SHOWER STALL NOR MS 1111110111 INN P O an um am ass a`
SERVICE/MOP SINK WM Nig MN INN.NM ON ON
TOILET IMO alli ail 1100 MK MIN 0011 N NMI ie ONO 0110 N
URINAL iB II1M NM ma
WASHING MACHINE CONNECTION t :0110 MN
WATER HEATER ALL TYPES �" arr=ant
WATER PIPING s t _ M I u o pm
OTC _.._ - � .. _ -MN 1100
. OM ININ IMP
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INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES)( NO I 1
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY1 OTHER TYPE OF INDEMNITY i 1 BOND ? j
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 L j
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 compliance with all Pe' at provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME U:l'tYsd'1-iud 1\,1 ..-5, 1,) 1 LICENSE#[ et Li' E
MP' ,1 JP!, j CORPORATION L 1#i 1PARTNERSHIPL,y t#I. LLG . #
COMPANY NAM t ADDRESS
d t n S1zS�� � t3e. ► C ,tti t iat 1��. {{rZ,r,�� 'i t� kI.��t C
CITY !STATE ) ZIP( 62�u r I TEL[C� �\I "" Se, v._
FAX 1 1 CELL EMAIL t 11YL_ cyL,-44 N 41uV14...Ac .,Ca ielei
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
Li—` CITY k I/IAjr,h k-L'1/t, MA DATE1 I PERMIT# J411-/17)-,'9'._C7e
JOBSITE ADDRESS1 5 IA_> Utz S OWNER'S NAME �_ ___
- ' OWNER ADDRESS ( I TEL; 3` .--Gc,•)..5 IFAX1
TYPE OR OCCUPANCY TYPE COMMERCIAL j I EDUCATIONAL L J RESIDENTIAL I SA
PRINT
CLEARLY NEW:j I RENOVATION:i I REPLACEMENT:,(;1 PLANS SUBMITTED: YES; NO I
APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 , 8 9 I 10 11 I 12 13 1
BOILER ..._. •_I .�..
BOOSTER I`
CONVERSION BURNER : .. a
.:.e•.� •mac-'�+st•, � 1 ?s- M,�.; is
COOK STOVE _ I , t I,
i s .,,a T - , =-,a
DIRECT VENT HEATER R I L ', 7--
DRYER
FIREPLACE t ` r *;
FRYOLATOR Le
FURNACE 2 f s
GENERATOR rIt i L- � _c _ T
GRILLE m, ,� .z
INFRARED HEATER .A. ;; / - .. . - . 4,...*,,,,-„,.,
LABORATORY COCKS ` ;
MAKEUP AIR UNIT A k
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OVEN
POOL HEATER .t t-. t — , . _. : . .
ROOM/SPACE HEATER atrittegri ,.-- _' . ns - _, ,-
ROOF TOP UNIT
TEST g-i0ra..l-_-aVr.lat.ti7-4 t,4,„1516÷,.,,,..4.. „,, .s.aal!.,1/4 45M-ga,.
UNIT HEATER t ,
1 4
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UNVENTED ROOM HEATER sI' 3a 4 '
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WATER HEATER .. $, , _ >._
OTHER t=
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 YES,j NOj
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY I%C f OTHER TYPE INDEMNITY i , BOND ( 1
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 Li AGENT I J
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 compliance with all.Pertinent p ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME II, . 'i�1.G 'L; ' I.LICENSE#1 `t• SI AT
MP NI MGF I JP( I JGF I ) LPG![..1 CORPORATION[;,}#[ PARTNERSHIP! i# LLC( i#
COMPANY NAME _ a.MAS ItAlli,le-L likADDRESS Tt C' t'Lr: --.Y ,J i 1,,, ,c,i..) i
CITY i.)c.., �f L 0,, _0 1fL. STATE;Y\;�,p j ZIPL t3 a c 1 {TEL a i-7.1 t 7 -,S S _ .1
FAX CELL 1EMAILt {V}�..G' t 10-C,LodYv10.s'f`C.,>e2pLt.t_._jr„„ _: e.C;t'j,,. 1
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