HomeMy WebLinkAboutBLDP&G-20-006292 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK )4-6 ;
ti '°_ '�j rL. MA DATE -_CITY �O .4 i k.0 ) .7/.L?zOtPERMIT#.
JOBSITE ADDRESS I L1_GA- (...Al_i .a _...__ NER'S AM ... IGLM...t' .,_!_-e.-,r.:L...a._._.._._._....._._,...'1
POWNER ADDRESS ....,...._......_..,,.__.._..,._......-.---._._.........................__...__..........._..._........_._......................... .._...- ......_. EL -3..7. rs. u__._._....... 1
TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL [Q RESIDENTIAL
PRINT
CLEARLY NEW:El RENOVATION:LI REPLACEMENT:E PLANS SUBMITTED: YES 0 NO
FIXTURES 7 FLOOR—* BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
CROSS CONNECTION DEVICE I '. II.-......,... - _ 1:. - __;I....... . t. ...-... ; _II .......__
DEDICATED SPECIAL WASTE SYSTEM L. ..,_ II .._... I ! ._., ` ? .__...II _ .
DEDICATED GASIOILISANDSYSTEM I_ ._..,..,II,.w..__ � ._.__.. .. I . WII: ,�_. ..., �,.. - .IL�W_: IL-. _ I _-.__ I.�...... .I
DEDICATED GREASE SYSTEM ....., I I ._.___: . I
MI � � I �.
DEDICATED GRAY WATER SYSTEM ...w„_,b :.1..Tm �� �_.._:.�.�_._I I.,,,,_.JL...,>,_11„... .,...._:_...._ _.�I1._._,....JL_.,..__ ..w_a,..._... _.:_
DEDICATED WATER RECYCLE SYSTEM IT I,.... _e I. ....._- ._.._ I _._._. . . .- :II...--- - _., - -_I.... _11_, .-.--I _ -. .- L, : I,_... ! _,_ . I
:.
DISHWASHER I_. I ,,i " I I I..__
DRINKING FOUNTAIN ........ . . . .1 ..:.. I, I . . 1—..11... ..„I._ _.I I ......... 1.. �1 L:.., I _.::: !I
FOOD DISPOSER .L .. : .1 I-- 1 . I I I _..
FLOOR/AREA DRAIN
INTERCEPTOR(INTERIOR)
KITCHEN SINK 1.. ,i I 'I 11-._ it ,I r I
LAVATORY .. ._
ROOF DRAIN .JI:.- _r l..,. -1 I _ :WII. r_.. .
SHOWER STALL I. ._ .. __ I I I_... j
SERVICE/MOP SINK I_.. .._..Ir....:.,._._ 4: ..........III- .? I _. .i I.... JF7,7 , ::.:II_ . - 1...---.-(1—I :� ...'
TOILET L_ IL I ? I ..... L _.. y i
URINAL 1___. I._, . 1Ji 1 1 ,.. L_ . ! IL i _.. I
WASHING MACHINE CONNECTION _,11._..- i ..... I L :I ' ...- ! . ( II ... .II I..__ i 1
WATER HEATER ALL TYPES I it I '._ 1 I I i
WATER PIPING I i ::. :� --._� I ( _. !II.,..: _. I . .. 1771 - __: ill. . ) ,:.. _I
OTHER I I _ I 1 ' iI
c ,..u... .I_e_.. 1 _;I 1 I a 1 I LL. I .
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESI NO 1 1
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Ic' OTHER TYPE OF INDEMNITY Q BOND 0
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 El AGENT D
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 provision of the
Massachusetts State Plumbing ode and Chapter 142 of the General Laws.
PLUMBER'S NAME 1.... .9 1. ..__,.d .., ..AQ._ LICENSE#[Nal
SIGNATURE
MP JP lig Pro P ' CORPORATION D#_.............__........_..._..__3PARTNERSHIPIJ#_.___...__.._.._..__..._I LLCr_71# .._...___.............._...._........I
COMPANY NAME c P Ttc ADDRESS
CITY ..,11........._.l...a. .M0_v..._� ................... STATE ,.. —I ZIP _.. ......2, G7.3._I TELr77-(� _IT___ ...Q VL...Z I
FAX CELL EMAIL ,C�.. ._ T
alb"` - ._
CfcM1f1 ('1D 'j , _.,........
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
tIs ) CITY �" V c->N/ MA DATE --- •_7 c7 PERMIT# /' /��` -W—0Lx°a92
JOBSITE ADDRESS 7(-AA,-w/ct , I
j OWNER'S NAME ' �nr'5 T f'�,/i aG OWNER ADDRESS 1 TEL -- ��_-'^ i 5-1FAx° -__.--__ __!,
TYPE OR OCCUPANCY TYPE COMMERCIAL;] EDUCATIONAL J RESIDENTIALk
PRINT
CLEARLY NEW:.] RENOVATION:J REPLACEMENT: PLANS SUBMITTED: YES'] NOV
APPLIANCES Z FLOORS—. BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER .a __
1 I 1. _J I 1 I _ I __1_ __J
BOOSTER I. t I I , � —J _ —
I_I I_._ I___
CONVERSION BURNER i__1 l I I I I 1 1 I ___If' I
COOK STOVE I I _ 1 - I 1 1_I-1 _���_I_I� I
DIRECT VENT HEATER IIIII _J�J -I—J I 1_ 1
DRYER" 1 1 ( 1 _ 1 _ 1_I_ l __ I I� 1_J
FIREPLACE I I I I I 1_.._J l I __l I I_ I _I I
FRYOLATOR I I I _ I _ I I I I i _._1 _I __I —J
10 FURNACE -_—_! I I I_ 1 ! _! E 1_1 _ �1 _1_„ ( ;
I GENERATOR _ 1- ` I I i
GRILLE i ..- 1 1 __ _._1 ' r _`—J_J' ___I _J _.
i _ _ . _J ._.I . _..._I
INFRARED HEATER -J ... I _____1_ 1 _ _. _ I I j __I -- --
—J ) I 1 J
LABORATORY COCKS I I ____`.�._ 1__ 1 I.__J__..__I__ I.r J___1 1--_.
MAKEUP AIR UNIT ___ I�J I _-1 ___ 1 _I _ i —1. __J I
OVEN I _____I___ I -_- I ' __ 1 ____I ._ ____I ___ ! ____I j.___._I __1 —
POOL HEATER I J .1 i_____1_____I 1 _I J.____ _ i.___..J____J 1
ROOM/SPACE HEATER _____J !____i 1 _I __ '_ 1__ I I _-_ 1 _ I __._. J —1
ROOF TOP UNIT _.__...1 i ( _ I I I I
TEST _.. ____._ '_._. I_ J_____I�� I_ 1 it
UNIT HEATER _ �� _ _ _�'- '
UNVENTED ROOM HEATER J �__J ` _____... ____.._.'1 I._.____1 1___1______J ___1___—_J _.____i _____i
WATER HEATER / I —I. ___,___ I___.._._I _ I I__ I _._I I _
J
OTHER I 1 -_ i i I _ _I_______J v; I 1 1' i.__..._1 '
I i I 1 I _I ; - I . I I _I _J
.... .. _.. I 1 I 1 I ..1 _ I_ I 1 I ... '
t INSURANCE COVERAGE
ZI have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 1NO I
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY l OTHER TYPE INDEMNITY BOND Li
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 ^I AGENT _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 provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General La- . Q
ill rC
PLUMBER-GASFITTER NAME / / I LICENSE# SIGNATURE —
MP ,_I MGF_,_.J JP JGF J LPGI J CORPORATION']#' ('d PARTNERSHIP I LLC:_,_1#:
/_ 1
COMPANY NAME: r't ( - ' J i4. .ADDRESS6? (O j Y7 ` r l� 1
CITY .i ' C( ✓(/®J __I ZIP 6 7473-iTEL 7Y Try .../ .Z
FAX
1 CELL EMAIL . ‘,15er•• A ciP`[ tSto Q if/--q-r L_- C d Am 1
a I}1-
I
ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
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