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Home My WebLink AboutBLDP&G-20-003212 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK � CITY V �A D/g� c� ]pER��# / - _�^��`/"��` - - - -�� _- . .~ . JO8SITEADDRESS OVVNE °,�R'SNAME _C�^�.��/��L/ Yto��— __ � / . 0VVNERADDRE8S � TEL �FAX' NL ---- - --- -----� — -- � ^ - — --�� « ~- - -- -- 7 TYPE OR OCCUPANCY TYPE COMMERCIALQ EDUCATIONALD RESIDENTIAL�� PRINT CLEARLY NEW: RENOVATION:Ej— REPLACEMENT:Ej PLANS SUBMITTED: \ESE2 N 0 X1 FIXTURES FLOOR— Bmw 1 2 3 4 5 0 7 8 9 10 11 12 18 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM tx 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 wo—OWNWIMMKOMMOMW LAVATORY ROOF DRAIN SHOWER STALL SERVICE MOP SINK TOILET 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 NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW - LIABILITY INSURANCE POLICY X OTHER TYPE OFINDEMNITY BOND �� OWNER'S INSURANCE WAIVER:|am aware that the licensee does not have the insurance coverage required by Chapter 142o|the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: 0VVNER �� A�ENT F7 SIGNATURE 0F OWNER ORAGENT 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 iance with all Pertinent provision oxthe Massachusetts State Plumbing Code and Chapter 14zof the General Laws. PLUMBER'S NAME L|CENSE#h [�59@ K 2--� � S|G"ATURE �� mP�� JP�� CO —^RAT0NEI# «PARTNERSH|PF F—' [—@ —�# "LLC # � COMPANY NAMEADDRESS~��+_� _ y � CITY[_ STATE| 8A�� Z|P � TEL | ''" � _u-� ___ _ _ � FAX _ �CELL � EMAIL - �- / /l/� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK" ; f- J_ CITY. 'L 00,-r11(`t_A 1,`=—MA—DATE I aial1l jPERMIT-it-/i2f—S d—00,gall eZ a JOBSITE ADORESS1 7,%j I rgrA1 l..e ihrr nOWNER'S NAME c r 0-i 1 L AL.e- GOWNER ADDRESS TELJ 1FAX J __ .1 TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL a RESIDENTIAL 0 PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:1 r— PLANS SUBMITTED: YES II 1 NO APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER _- _ -! t a.. - . n i ._. ' .- __ _____ BOOSTER I I s 1 , i ' i.� -, CONVERSION BURNER _ .. - f� ' eitailu` COOK STOVE J , ..i ' ._ al DIRECT VENT HEATER .� ,_ _ ,_ „ 1. DRYERa1 I FIREPLACE FRYOLATOR +' FURNACE ' I.,. °� �W . I _ 4----„, GENERATOR ; - _T -- . * . - . ,.- m _ ...a--,....-.. .„a w GRILLE s _ INFRARED HEATER v LABORATORY COCKS 1 r f MAKEUP AIR UNIT 21 u4li OVEN ( fj �...�. _I I ._ POOL HEATER ` ROOM 1 SPACE HEATER I i {, a ROOF TOP UNIT � 1e , �w_;; [ .,' TEST _ 3,_ _i UNIT HEATER a UNVENTED ROOM HEATER on_ isin---__ En In .1 !innila WATER HEATER OTHER I .� IIr t - 1. '� .. )j iQ.'C,�lui.:h�.'inTv?Sw:A`:YSAt*ts.vnS%nt'.ir.,PYB£[NrzG:zir,NTAXi6iiJiaSTA1%C . . y_...—' '._ 1—..,..,„�1_.. ..- 'a_..-.� 5... A` n INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO 121 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 comh al' `� nt provision o the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. d PLUMBER-GASF►TIER NAME 1 Y IG I _ LICENSE#1 15930a SIGNATURE v MP MGF L i JP❑ JGF 0 LPG'D CORPORATION s #I 1 PARTNERSHIP D# 1 LC D#? COMPANY NAME:j , VLr ,Q 1,� f,,,.',�ADDRESS` '' i 1 CITY I . C�i 1Ct I ! STATE, mfi ,ZIP in L, JTEL . FAX ' CELL ..r,:� EMAIL�:.�-.�.��..,>.