HomeMy WebLinkAboutBLDP&G-20-004657 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
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`-e 1 CITY t t6 /12Nl�4 V1,t"11 1 MA DATE I ,PERMIT# �.go-112 5 '7
JOBSITE ADDRESS [(p ' > ,e '�.V'AA1y1 A>to , _� OWNER'S NAME (.aYa S L
OWNER ADDRESS _.. �_.. TEL $ -Sc) w_. FAX L
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TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL I 1 RESIDENTIAL J
PRINT
CLEARLY NEW:I I RENOVATION:I REPLACEMENT::X' PLANS SUBMITTED: YES 1 NO,
FIXTURES 1 FLOOR-. BSM I 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB r �. t �„ p, £ f '
CROSS CONNECTION DEVICE f I
DEDICATED SPECIAL WASTE SYSTEM ia' .1_ 4 1 I u
DEDICATED GAS/OILISAND SYSTEM 1
DEDICATED GREASE SYSTEM OOP 0011.0011.111111110.111. O 1111101iiiiis
DEDICATED GRAY WATER SYSTEM # r + MIIIMAII.
DEDICATED WATER RECYCLE SYSTEM MIK
DISHWASHER ` )
DRINKING FOUNTAIN 9 i
FOOD DISPOSER 'NW t MO a - ., . MIK
FLOOR/AREA DRAIN ".�.,"
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INTERCEPTOR(INTERIOR)
KITCHEN SINK MN ailing=I
LAVATORY t1 1 '
ROOF DRAIN , :�:.. _I M
SHOWER STALL i _ M IIIIIMMI1 M SIM
SERVICE/MOP SINK . i` - . . .`, 1111.N IIIII Milk MIN NM
TOILET MIMI
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URINAL
WASHING MACHINE CONNECTION t isimt,
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WATER HEATER ALL TYPES VA NON an
WATER PIPING Tmellak all.MIMI OMR IMIII MI 11101111.1141 ON
OTHER I i M
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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 Ix 3 NOR )
IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY p OTHER TYPE OF INDEMNITY i ? BOND I,...
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
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 P ' rovision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. c -
PLUMBER'S NAME i .t-/t j NAL ,+ ,�,q ,.�-}
IL1tYZ +.-.`"J ) 'LICENSE ? E
MPxI JP L ) CORPORATION[_ I# IPARTNERSHIPI I#[ JLLCf._]#[
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COMPANY NAM „ ADDRESS C },C�41-V,Y4 rZi_,i 1 OIMAJ C L_Li
CITY STATE; ZIP TEL r
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FAX CELL t1 EMAIL C rCpC t -e-c- srn ,8 -Z Lr ,m.,1 ,R,/4, to i ,
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R4ASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
►' CITY 1 i', L,1M�01it�1'�'� I MA DATEI
PERMIT#! /�" 6xl �5 7
JOBSITE ADDRESS' ( C-tr rYS Z tL�vi.Jt-i C r b la-. j OWNER'S NAME '
(� NAME k-t
OWNER ADDRESS I TELsi�'-S��'1- FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL! 1 EDUCATIONAL Li RESIDENTIAL P,j
PRINT
CLEARLY NEW:( I RENOVATION'i ! REPLACEMENT:'X` PLANS SUBMITTED: YES 1 i NO1
APPLIANCES Z FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 1
4aA_
BOILER i ' 1 ` _. I
BOOSTER t Mai__,
CONVERSION BURNER 45,64 _ .
COOK STOVE _ I ¢
i
DIRECT VENT HEATER ' '
DRYER -.�-,�.�.�:,� "� 4
is
FIREPLACE . f. _ 1 ; .'_ ,►.., r_).. Al,' }V _ k . •
FRYOLATOR
GENERATOR , — I I�- f- - - /,
GRILLE
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INFRARED HEATER — t It { ,
LABORATORY COCKS .•, io.-`r'` :,• , _ -� .,., - .
R Y
MAKEUP AIR UNIT i - i+ '
OVEN g
POOL HEATER .� . -
ROOM/SPACE HEATER T� _ - - I -- Wtria
ROOF TOP UNIT i £ x
-r =" = T, 1`.a y ' - to ,.a ;r
. -
TEST r k-m.i > . t A .
UNIT HEATER _�A, ,i::, a - � a ¢. -
UNVENTED ROOM HEATER . ` _ .
,... Vti ;yeVSs a + _ A?;,gamic= 7-.•.F . .- _ ., s�`
._- : .
WATER HEATER
OTHER J F w v
, gym
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�.1. `i
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES KA NO (_,
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ;h: OTHER TYPE INDEMNITY BOND I
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 J AGENT Li
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 Pertinen ision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. -`
PLUMBER-GASFITTER NAME k-kyY1- -I( ij ifyk_c L, k 1,3 1 LICENSE#[}4.7%91-J SI AT
MP . MGF 1 I JP 1, I JGF I 1 LPG!L i CORPORATION I I#I I PARTNERSHIP # LLC I 1#
COMPANY NAME'_. ?_ Oct 1-vekr�I.A11,02-1: DDRESS• ( ,Ca 1L� 5 _ I I11,,1,�,r,t,' J
CITY 1 STATE ZIP` rLITE. J
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FAX CELL[ EMAIL i E n�`a t D dwltk " IAA._00t.12-C. sS ert